5 enduring healthcare insurance tips for consumers
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In a time of flux in healthcare policy at the federal and state levels, consumers need guidance in steering through the complexities of the healthcare system.

The new presidential administration may bring changes in the new year, but changes also may come from your own healthcare plan as the new plan year begins. It is important to check your plan documents for changes in your copays, deductibles and network participation of doctors and hospitals.

Regardless of how public policy, healthcare systems and insurance plan designs evolve, healthcare and insurance costs will continue to be significant factors in consumers’ personal budgets. While there is much that could be said about using health insurance benefits and managing medical and dental costs, five simple tips can go a long way toward clarifying what is most important to remember.

Key to the tips is the concept of the provider network: the group of all doctors, hospitals, laboratories and other healthcare providers that agree to accept an insurer’s contracted rate as payment in full for their services.

Regardless of the type of health plan — for example, a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) — there is almost always a strong financial incentive for the consumer to use in-network rather than out-of-network providers.

Unfortunately, knowing whether your provider is in or out of network can be difficult. According to a recent New York Times article, insurance plan directories of providers are often inaccurate and out of date. Doctors may be listed who are no longer accepting new patients or participating in the network. To add to the confusion, a single insurer may offer different plans with similar names but different networks.

Here are the five tips that may make your healthcare journey easier:

  1. Make sure you know whether your provider is in network or out of network. Check with both your provider and your plan. Check your plan documents to be sure that you name your plan correctly when making inquiries. Remember: Out-of-network doctors such as radiologists and anesthesiologists may be involved in your care even if your hospital is in network. Make sure to ask before your appointment or procedure whether all doctors caring for you are in network.

  2. If you are going out of network voluntarily, understand how your out-of-pocket expenses will be calculated. You will almost always pay more than you would in network, but how much more will vary according to your plan.

  3. If you receive a “surprise” out-of-network bill for emergency care or otherwise, determine whether your state law protects consumers and whether it limits your responsibility to the in-network amount.

  4. Understand that you can talk with your providers about out-of-network fees. Try to negotiate costs by comparing your provider's’ fees with the typical local charges for specific procedures.

  5. Familiarize yourself with the key terms and principles of health insurance so that you can be a better advocate for yourself as you navigate the healthcare system.

Before you contact your insurer, check your plan documents. They may make clear, for example, how your out-of-pocket expenses are calculated for going out of network. For example, if you are in an HMO, you generally will have to pay the full cost of out-of-network care (an exception may be made in emergencies).

If you are in a PPO, the plan may pay a percentage of the cost — but they will calculate the cost based on what they define as a “usual, customary and reasonable” (UCR) fee, which by their definition might be only what they would pay an in-network provider or perhaps some percentage of what Medicare would pay.

You will have to pay the difference between what your insurer allows for the service — the “allowed amount”— and what your provider charges. You may have a separate out-of-network deductible and your insurer will not pay anything until you have met it.

Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation’s largest repository of private healthcare claims data, comprising over 21 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. 


The views expressed by contributors are their own and not the views of The Hill.