A new year brings fresh starts and new goals. This feeling of goodwill applies to most things except your health plan. Yes, that sinking feeling when you realize that come December, you’ve finally just met your deductible and out of pocket maximums, and now you have to start all over again.
We’ve all been there. You open your mail, email, or SMS message informing you of a medical charge you scarcely remember.
I learned the hard way how to navigate this wild world of health insurance. I’m sorry to say, this often entails reading the fine print, spending time on confusing website portals, and being on hold for an astonishingly long time while listening to repetitive jazz.
I can help you save some time and money by summarizing the important bits you need a magnifying glass to find in your medical policy or elsewhere. It’s likely you have paid for services you aren’t responsible for.
The “No Surprises Act”
What’s surprising is how few people know they have rights to protect them. In California, Assembly Bill AB 72 was enacted in 2017, and on the federal level, the No Surprises Act (NSA) in 2022. Both have largely the same intent:
Summary of NSA protections:
Bans balance billing for non-emergency care by out-of-network providers and additional services like anesthesiology or radiology at in-network facilities.
Bans balance billing for emergency care at any facility even if out-of-network and without prior authorization. How can you pre-authorize an emergency?
Bans out-of-network cost-sharing (like coinsurance or copayments) for most emergency and non-emergency services. Meaning you can’t be charged more than the in-network cost for these services.
Health care providers and facilities are required to give you notice explaining applicable billing protections, and who to contact if you have concerns these protections were violated. You must also receive notice of and consent to being balance billed by an out-of-network provider.
My family accrued an unusual amount of emergency medical bills over the last few years, andI have never failed to get emergency charges overturned through an appeals process.
DOA: Dispute, Overturn, Appeal
You have the right to appeal any denied claim. You can find this option in your member portal on your insurance provider’s website. An “appeal this claim” selection should be listed under each individual claim - and accompany your Explanation of Benefits (EOB). If you don’t see this, that’s the time to pick up the phone and get a representative on the line. Be patient with the jazz hold music.
Based on the No Surprises Act, there are two solid reasons you can overturn a denial by your insurance company:
1. Ambulance transports and other emergency medical services
If your family member is transported to a hospital via ambulance, you are not responsible for paying an emergency transport provider at an out-of-network level.
No one stops to ask if an ambulance is in network when you call 911. The closest available emergency medical support will respond. You have no choice in the matter whether you are calling for assistance, or a good samaritan is. And this is exactly what you tell your insurance company representative.
The same applies for the hospital you or your loved one is taken to. If the hospital is out of network, you can appeal for the claims to be processed at an in-network level. If the hospital is in-network but a doctor who provided treatment during that hospital stay is not, you can appeal this as well.
2. If you are unable to find an in-network provider for care
When you do have a choice of doctors, there are two scenarios that should allow you to choose an out-of-network provider for your care and still have your insurance cover the cost at the in-network level:
Distance: There is no other qualified provider / specialist or in-network facility nearby (or taking new patients). Nearby usually means within a 100 mile radius, check your plan; or
Specialty: In addition to the distance factor, if your specialty physician no longer takes your insurance, and you wish to stay with them, you can ask for a continuity of care, especially if your case is complex. It helps if your doctor provides documentation to include in your appeal.
How to talk with your insurance representative
Ask to have your claim re-processed at an in-network level of coverage due to one or more of the reasons above (#1 and #2). Usually this is enough. If this doesn’t work, ask to appeal the claim for the same reasons. Mention the “No Surprises Act” if they hesitate about emergency services.
Don’t pay up front
Be cautious if you are asked to pay for any service up-front. Always request that your insurance be billed first, and any remaining balance be invoiced to you. It’s always more difficult to get reimbursed by a provider or insurance company.
The most common reasons an insurance company will deny your claims are:
The providers are out of network, or
Treatment was not medically necessary.
We have already covered the in and out-of-network criteria. But what about “not medically necessary”?
If you or a family member on your plan is ill enough to be hospitalized, or requires the care of a physician - treatment was typically necessary. Insurance companies employ their own consulting doctors to review claims and make coverage decisions - even though they have never seen or treated you in person.
This is when you should appeal the decision, and request a “peer to peer” consultation. This involves the insurance company doctor speaking with your doctor about your case. Any medical history, notes, or other information that can support your appeal should be sent to your insurance company. Don’t feel guilty about notifying your doctor to participate in the consultation and prepare for it. They want to be paid!
Document everything
Remember to always get the reference number for any call you make to your insurance company, including the date and at least the first name of the person you spoke with. Take notes. You will be sent a letter and a case number via your portal or snail mail when you appeal a claim. Keep this information to refer to. All claims have a timeframe within a decision must be completed.
Appealing beyond your insurance company
If your insurance agency digs their heels in and upholds their decision not to cover your claim, you have a higher level of appeal open to you. You should be given this information in a denial letter from your health plan.
At the federal level, there are a number of important statutes applicable to healthcare insurance. The McCarran-Ferguson Act says that even though the insuring or provision of healthcare may be national in scope, the regulation of insurance is left to each individual state.
That just means if you are struggling to locate information within your state - or your state doesn't have an external review process that meets the minimum consumer protection standards, the federal government's Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your area.
In California, the majority of heath plans are regulated by either the The Department of Managed Healthcare (DMHC) within a branch dedicated to health plan oversight, or the California Department of Insurance (CDI). To find out which governs your plan, visit www.insurance.ca.gov.
Appealing beyond your health plan may sound like too much work, or too intimidating. You have nothing to lose but a little time by submitting your documents. If you need assistance filling out the form - once you get a human on the phone, they are actually quite helpful. You can prevail and be relieved of substantial financial debt. At the very least, you will learn whether the billing you received is accurate.
Providers do have a heart
Let’s say all your appeals were denied. This is actually more uncommon than overturning a claim if you have a legitimate complaint. Please note I am not advocating anyone should try to overturn billing that they rightfully owe.
However, let’s say you end up owing a tidy sum. There are a few options you can pursue to lessen the amount or give you enough flexibility to make reasonable payments. Contact your provider and ask these questions:
Will they accept a discounted cash rate on the balance?
Can they assist you in setting up a payment plan?
Do they have a financial aid program? Most larger medical providers do. Ask for an application or search for it on their website to see what the requirements are.
You can settle your bill this way rather than break the bank all at once.
Prescription medication & co-pay assistance
Another way to save on your healthcare is taking a bit of time to research prescription medication assistance programs.
The cost of many medications per month can be astronomical. In addition to approaching your insurance company about coverage, do an internet search for the name of your medication followed by “consumer assistance” “consumer rewards” or “co-pay assistance”. Many manufacturers have membership programs that can significantly lower your out of pocket share.
There are also Prescription Drug Savings Cards you can obtain from your doctor, pharmacy, or simply research online. Some of these include GoodRx, WellRx, and OptumPerks.
For most copay cards, there are a few main requirements:
You have commercial or private insurance.
You do not have government health insurance, such as Medicare or Medicaid.
Depending on where you live, there may also be laws that restrict the use of certain copay cards. California banned the use of coupons to purchase brand-name medications that have generic equivalents.
Government health insurance exceptions are due to anti-kickback statutes that prohibit manufacturers from inducing the purchase of an item for which someone may be reimbursed by the federal government.
For many cards, there may be an expiration date, maximum number of times you may use the card, or savings maximum. It varies by medication.
Summing up
The reality is, the modus operandi of insurance companies is to routinely deny any out- of-network claim. To be fair, most are not stopping to look closely enough to dissect what falls under the “No Surprises Act” and what doesn’t.
When in doubt, appeal. I have overturned close to a million dollars in medical claims simply by understanding these few steps. I realize my situation is not common, yet you can leverage this knowledge to save costs if you find yourself in any of the above situations - because those are not unusual.
Good luck and good health!