12 Ways to Optimize Your Health Insurance
When it comes to your health and cost of care, you have more power than you think.
May 12, 2020Your Care
Deborah D. Gordon has spent her career trying to level the playing field for healthcare consumers. She is co-founder of Umbra Health Advocacy, a marketplace for patient advocacy services, and co-director of the Alliance of Professional Health Advocates, the premiere membership organization for independent advocates. She is the author of "The Health Care Consumer's Manifesto: How to Get the Most for Your Money," based on consumer research she conducted as a senior fellow in the Harvard Kennedy School's Mossavar-Rahmani Center for Business and Government. Deb previously spent more than two decades in healthcare leadership roles, including chief marketing officer for a Massachusetts health plan and CEO of a health technology company. Deb is an Aspen Institute Health Innovators Fellow, an Eisenhower Fellow and a Boston Business Journal 40-under-40 honoree. Her contributions have appeared in JAMA Network Open, the Harvard Business Review blog, USA Today, RealClear Politics, The Hill and Managed Care Magazine. She earned a BA in bioethics from Brown University and an MBA with distinction from Harvard Business School.Full Bio
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Taking care of yourself during the COVID-19 pandemic may feel like an elusive goal. Health experts — and the sponsors of National Women's Health Week — urge women to be active, eat well, and take care of their mental health. But some days in quarantine, it can be a feat just to shower. Disruption, grief and anxiety can make it hard to proactively take care of yourself.
Yet if COVID-19 shows us anything, it is the power we have as individuals to take meaningful, individual actions to protect our health. Staying home and wearing masks are the most powerful ways to break the virus's insidious spread.
Why not, then, claim that same kind of power over more of our health care experiences? Here are 12 proactive steps you can take to increase the chances of getting what you need — and want — from the health care system.
That's a little like saying, "Look into your crystal ball and predict your health care future." It may seem impossible to know, but you have some of the information you need to decide between a high-deductible health plan (HDHP) with lower monthly premiums or the reverse. If you have a chronic health condition or anticipate getting pregnant or having surgery, you can assume your costs will be higher. It might be worthwhile to pay higher monthly premiums in exchange for lower out-of-pocket costs down the road.
On the other hand, if your cash flow is tight or you don't expect to need health care services, you might prefer a lower-premium, higher-deductible plan. You risk financial exposure if you need more care than you expected, but if not, you may come out ahead. Depending on your tolerance for risk — and your best estimate of your needs — that might be a smart bet.
Some state health insurance marketplaces let you calculate your costs in a typical scenario and a worse-case situation. These are still only best guesses, but they can give you a sense of the range of costs to plan for.
If you're stumped, companies like HealthSherpa, eHealth and PolicyGenius help consumers compare plans, usually by estimating costs and identifying plans that include your health care providers and medications. Jellyvision helps employers support employee health insurance decisions, and predictaBill compares your specific options across employer and marketplace plans.
These are the health care professionals and facilities your health insurer prefers. Usually, these are lower-cost providers and might be smaller or less well-known, but they may still provide high-quality care. Your health plan likely pays them lower rates and may create incentives for using them, such as lower copayments (aka copays). If you have specific providers or facilities to which you are attached, losing them may not be worth the money you could save. But if you're relatively unattached, consider those providers your health plan favors.
Certain conditions require medical specialization, but for many health needs, clinicians with other credentials can provide the care you need for less. Social workers and psychologists usually charge lower rates for psychotherapy than psychiatrists. Midwives may be appropriate, lower-cost providers for low-risk maternity care. And you may be able to choose a nurse practitioner as your primary care provider, depending on your state.
In our 2019 study, my collaborators and I found changes in treatment plans (49%) or prescriptions (29%) were often made when providers and patients had conversations about costs. These findings suggest there may be lower-cost alternatives available and appropriate for your needs. But you may have to ask to unlock those savings opportunities.
Health insurers theoretically negotiate lower prices with health care providers, but it doesn't always work that way. In researching my book, The Health Care Consumer's Manifesto, I interviewed a nurse whose Medicare prescription plan refused to cover one of her medications. Out of frustration, she finally asked the pharmacist what it would cost if she just paid cash. That magic question revealed a lower price than her health insurance copayment, with less hassle. Normalize asking key questions: "What would it cost if I pay cash?" or simply, "Is there any way to make it cost less?"
Checking a prescription discount program like GoodRx can also help you save money by paying cash for your medicines, but check different sites and even different pharmacies. Drug prices can vary wildly and the cheapest place to get one drug may not be cheapest for all drugs.
Painful as it is, dive into those details. Medical bills may seem unintelligible; the billing codes providers use on the claims they submit to insurers for payment were not designed with consumers in mind. Check for obvious mistakes, like if the dates of service listed are wrong or if a procedure or service never happened.
Ask for an itemized bill to get as much detail as you can. Search the internet for specific current procedural terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, which may appear on your bill as "service codes" to see if anything seems off. You can also Google the diagnosis codes, called ICD-10 codes, to make sure the bill reflects your actual diagnosis. If you're not sure, ask for clarification and further detail. Just asking the question could yield savings.
If you have a large medical bill, you might be able to negotiate. Ask for partial bill forgiveness. If you can pay part of it, offer to do so right away in exchange for forgiveness of the rest. Or, offer to pay in a few installments on a set schedule if they'll lower the total bill.
In 2018, hospitals provided more than $41 billion of uncompensated care; approximately 5% of nonprofit hospital bills go uncollected. That's significant for most hospitals and they may take less if it means they will get paid something over nothing.
Finally, if the provider won't lower the bill, ask for a payment plan. Typically, the monthly amount is based on what you can afford, often without interest.
If your insurance company denies your claim or request for coverage, appeal. Health insurers are required to provide levels of appeal; for example, health insurance marketplaces created by the Affordable Care Act provide two levels of appeal. Learn your rights and their responsibilities.
The Patient Advocate Foundation recommends doing some homework about what happened and why your claim was denied. Ask the provider who filed the claim for help. Appealing insurance decisions can suck you into administrative bureaucracy but may get you the coverage you need.
Success rates vary. One study showed that out of nearly 42 million insurance denials appealed by consumers with Affordable Care Act insurance, only 14% were overturned. A 2018 analysis of consumer appeals to the California Department of Managed Care – the agency that regulates most California health coverage – showed that insurers reversed their denials in 12% of appeals; the agency itself overturned another 42%.
Short of a formal appeals process, try escalating complaints within the health plan. If you don't get resolution from customer service, ask to speak to a supervisor or other leader. File a complaint, which you may be able to do on the spot. Or ask to speak to someone in a specific department, such as behavioral health (if you're trying to get access to mental health care) or medical management if you have a complex condition like cancer or diabetes. Clinical leaders may not be able to overturn insurance decisions, but they have more authority than frontline staff.
Depending on your health plan or your employer, you may have access to different financial tools to help you save money. Health savings accounts (HSA) pair with high-deductible health plans (HDHP) and let you set aside pre-tax money for qualified medical expenses. Flexible Spending Accounts (FSA) or Arrangements also allow employees to set aside pretax money for health expenses but are not tied to HDHPs.
Health care and health insurance can be complicated, overwhelming and costly. Whether deliberately or inadvertently designed to get you to give up, the net effect is the same. Don't let the system's complexity deter you from getting what you need.
Mastering the intricacies of health insurance may not be high on your list of priorities, but maybe it should be. If you're willing to invest time and energy in navigating the system, you have more power than you think.