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Understanding the Basics of Medical Insurance

As Foreign Service Officers and family members, we often must plan for the future. One of the least understood planning tools is medical insurance. This is especially important when you are posted to the United States.

Access to the Federal Employee Health Benefit Plan (FEHBP) is a significant benefit of federal employment. Yet, there is no other business with a system that leaves the payer so removed from understanding what goods they have purchased and what they will cost.

Prior to becoming the proud wife of a Foreign Service Officer (plus preschooler wrangler, and Embassy Staff Feeder), I worked in various medical fields for 12 years. I managed a dental practice, a veterinary practice, and an acupuncture practice. A large portion of my day was spent focusing on medical insurance coverage, maintenance, and follow-up.

Over the years, I was fortunate to work for health care professionals who sincerely cared for the well-being of their patients. They sent me to various courses and tutorials to learn how to navigate the medical insurance system and how best to advocate for patients. I hope that the following information will lead to a clearer understanding of your coverage and how to get the information that you need to best advocate for your own care and costs.

We begin with the basics of contractual agreements:

Your contract with your insurance company

When you pay monthly premiums to an insurance company, the insurance company is agreeing to pay a portion of your medical bills as long as the doctor you choose is “in network; ” that the services being provided are part of your plan coverage; and that your deductible for the year has been met.

Your contract with the doctor’s office

When you make a medical appointment and sign your new patient paperwork, you are entering into a contract stating the following: in exchange for medical care, the patient is responsible in full for paying all fees accrued for services rendered. The medical office is (usually) willing to treat the insurance provider as a “third party” and will, as a courtesy, submit the bill to the insurance company first.

Many medical offices will call your insurance company prior to your appointment to confirm eligibility and coverage for treatment. The medical office strictly considers this to be a “courtesy call”. They simply wish to be as certain as they can that the patient has coverage for the visit. This is why if a patient is not covered by insurance, they will pay in full at the time of service. The law states (and you’ve signed the paperwork, giving your legal agreement) that the balance due is always the responsibility of the patient.

The contract between the insurance company and the in-network doctor:

A doctor signs a contract stating that they will accept a discounted payment for services in exchange for referrals from the insurance company. When a patient needs care, the insurance company will recommend the health care providers within their “network” thus insuring patients (and therefore, income) for the doctor.

Given a basic understanding of how the system works, here are some key terms to help you understand your coverage:

Insurance Terms

  • Deductible: out-of-pocket expense prior to insurance payments.
  • Co-payment: what the patient pays for each visit to a medical office.
  • Year-end dates: the date at which the deductible starts over.
  • In-network: a doctor contracted with the insurance company.
  • Covered services: services covered by the insurance company, and what percentage of charges they will pay.
  • Write-off: the remaining balance purged from the final bill by the doctor in accordance with the insurance company’s payment.
  • Pre-authorization: an estimate from the medical office submitted to the insurance company that clarifies coverage and patient charges prior to service.
  • Usual and customary coverage: the assigned value of a service decided upon by the insurance company. This is done by taking a cost average from medical offices in a given area and assigning a “value” to the service that the insurance company is willing to pay. The insurance company then pays a percentage of their perceived value for the service.
    For example: Dr. X charges $100 for an exam. Insurance company Y considers the ‘usual and customary’ value to be $50, of which they pay 50% at $25. The patient (whose deductible has been met) pays a ‘co-pay’ of $25, leaving a balance of $50. The doctor charges the patient for the balance or gives a “write-off” and takes a tax credit by not charging the patient for the remainder of the service. Ask your doctor which way this will work in their office. Some insurance plans require the doctor offer a write-off of the balance after the patient pays his deductible and co-payment.

Always, always, always

Keep an insurance notebook in an easily accessible place. Use it to keep track of your coverage and record every phone call between yourself and your insurance company, doctor, office manager, etc. Include their name, the date, their phone number, your questions, their answers, how long any needed resolution will take, and any code that they use to track the conversation.

Inevitably, a question will arise with your insurance company or medical practice. Knowing the specific details of your coverage and/or previous conversations (especially with whom you spoke and exactly what was said) is the fastest way to get resolution. Otherwise, it is very likely that they will not remember the discussion or agreed outcome.

If you know what procedures you’ll have, prior to a visit, make two calls:

Ask your doctor for a price estimate for the visit. Ask if they offer “pre-authorization.” If so, ask what the turnaround time is and before your appointment, you’ll know the charges. If there is a delay, you can call your insurance company and ask about the status of the pre-authorization.

If it is a standard and simple procedure and they don’t offer pre-authorization, ask for the service codes and costs of these services. Make sure you know who will be treating you. With this information, you can assess your coverage by calling the insurance company yourself.

Ask your insurance company and ask if these services are “in network” with this provider, with these codes (or services). Ask if your deductible has been met and then ask at what percentage these services will be covered. Write all this information in your insurance book.

While the last step may seem redundant, it is important to remember that if there is a discrepancy or error on the part of the medical office, the patient is ultimately responsible for the accrued debt. Always.

With all this in mind, if you are dealing with a medical office that treats these questions with annoyance, consider it a red flag. If they are too busy, consider how they will work with you if your insurance company has questions or denies a claim. If the office staff resists, ask for an office manager and if they are too busy, ask to speak directly to the insurance company.

A good doctors’ office staff and insurance company will want you to understand your services and costs. If you don’t have a good office staff or insurance company you can seek services elsewhere. Please offer them the courtesy of telling them (gently, please) if they are not meeting your needs. There are few things that a doctor dislikes more than hearing that his staff is falling short and that he has to step away from treating patients to deal with managing an office that he pays someone else to handle.

If you don’t know the extent of the medical care you’ll be requiring, consider using:

  1. A case manager: employed in hospitals and larger practices to assist patients with complicated cases and insurance coverage.
  2. A patient advocate: licensed and credentialed to work on the behalf of the patient and assist with insurance billing and medical treatment. (The P.A. will need access to personal information, so please be diligent in researching reputable advocates.)

The fact is that medical staff and insurance company personnel are employed to assist patients with their care. Everyone receiving medical care and/or purchasing health insurance should be educated regarding coverage and treatment. Fees and policies should be easily accessible and clearly explained. Until this is a legal requirement, patients need to advocate for themselves and insist that medical offices and insurance companies provide transparency and clarity. It is not inappropriate to know what services are being received or what will be charged, in advance, but we must be educated about our own care for this to happen.

Liz Amen,
Brasilia, Brazil

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