24 Seven May 2018

Lorie Gardner
BE THE MASTER OF YOUR
HEALTH INSURANCE BENEFITS
The last thing someone in a healthcare crisis
needs is a surprise medical bill that he had no
idea he would be receiving. This can cause
undue stress on the patient and his family.
What is the solution? Know your plan, what
is covered, and how much it will cost before
you secure services.
This requires not only reading your health
plan benefits, but also liaising with the
provider of services to ensure the services
are covered.
You must also know if any pre-authorization
from your insurance company is required
ahead of time.
All services must be reviewed to ensure they
are in-network, which means they have a
contract with your insurance company and
your coverage of services will be optimal. If
the provider is out of network, you could get
a large bill for those services that would not
be covered by your insurance plan.
It is critical to understand the Explanation of
Benefits (EOB) that your insurance company
provides. The EOB is a report to you and
the provider of services on exactly how
the insurance claim was processed. It is
essential to review this to determine what the
insurance company has paid and what your
responsibility is. The EOB must be reviewed
carefully and can frequently have incorrect
coding, which can significantly affect the
amount you might owe.
Other terms on the EOB that are important
to know:
• The deductible is the amount of money you
have to pay before the insurance benefits
begin.
• A copayment is the specific dollar amount
that the insured is required to pay at the time
of a doctor’s visit. Co-payments are not subject
to deductible so it does not count towards the
out of pocket maximum.
• Coinsurance (allowed amount), after the
deductible is met, is an expense to be paid
by the insured that is a percentage of the
provider’s charge.
• Out-of-pocket maximum is the amount the
insurer has to meet in order for the insurance
company to pay 100 percent of the policy’s
benefits.
Here are some tips to help you handle your
medical bills and claims:
• Review all bills and EOB’s in a timely manner.
• Do not pay a provider’s bill until you have
verified and reviewed the bill and claim
carefully.
• Ensure that you have an itemized bill.
• Request medical records if needed for
verification.
• After ensuring that the bill is correct, verify
it against the EOB. The amount due from
the provider should match the subscriber
amount responsible for on the EOB.
• Review your online account for details.
• Call your insurance company with any
questions and request explanations on
codes or additional information requested
from the provider.
• Document names and a reference number
for every call to the insurance company.
• Obtain help as the process can be
overwhelming. Ask a family member,
friend, or hire an advocate to assist.
• Address high cost items and determine
if it is correct or if there is an overcharge.
• Compare prices and negotiate, if
possible.
• Call the hospital purchasing department
to find out vendors for big-ticket items and
call vendors to request costs. Ask if they
provide discounts, bulk rates.
• Meet and/or call the hospital financial
director to share any price differentials you
uncover and negotiate cost down.
Remember there can be errors in medical
bills and EOB’s. It is in your best interest
to become the master of your health
insurance benefits.
Lorie Gardner, RN, BSN, NBC-HWC, founded Healthlink Advocates, Inc., to assist people with all aspects of their healthcare. As private
nurse patient advocates and board certified health & wellness coaches, they partner with clients seeking assistance navigating the complex
healthcare system and those seeking self-directed, lasting health improvements aligned with their values.
www.healthlinkadvocates.com