I’ve been seeing the same doctor, going to the same facility, and receiving the same treatment for the same condition for two years. Every six weeks I have medication infused over a three hour period for an autoimmune disease I was diagnosed with in 2009. These infusions are what keep me free from serious illness and out of the hospital.
While this may sound dramatic, it’s a pretty common circumstance. According to the CDC, over 133 million Americans live with at least one chronic illness—one out of every two adults—that requires regular medical treatment. But even after going to the same doctor, visiting the same facility, and receiving the same care for two solid years, I still have to fight with my insurance company over billing issues and terminology every six weeks.
Wrestling with health insurance is stressful. With arguing over “tier two providers” and “in-network service” and knowing that every six weeks an error could derail my treatment, in many ways it feels like I’ve lost control over my own health. I will be chronically ill for the rest of my life, but I’ve taken the steps to navigate the insurance maze to avoid another nightmare of snafus.
The Horror Story
About six months ago the time came for my next infusion, so I swung into action as usual. I called the infusion facility to confirm my appointment and was informed that my insurance company was refusing to pay for the next treatment. It bears mentioning that the medication I receive—something that is used to treat several illnesses—costs slightly more than a semester at Princeton University. I was told that I could pay for the infusion out of pocket, which was not possible. With only 72 hours until I needed my medication, my only option was to get on the phone with the insurance company.
This is not exactly easy. Because the insurance company representatives are only available during regular business hours, I had to make these calls from work. I sat in my office common area on the phone with different representatives trying to figure out what the story was. After three days of speaking with my insurance company, things were still not resolved in time for my appointment. I did not receive my infusion that week. I can go without my infusion for an extra week or even two, but there is always the chance that I’ll get seriously sick because of it.
It took 17 days without medication, 20 hours of phone calls, and a mental imprint of the symphony version of Celine Dion’s My Heart Will Go On to resolve the issue.
There was a clerical error. Someone from the insurance company had wrongly labeled my infusion facility as an “out of network”, “tier three” provider when it is actually an “in network”, “tier two” provider. It took two weeks to locate this glitch through the maze of paperwork in my file. The representative I was talking to at the time said, “oh, here, lemme fix that.” I heard a few clicks on a keyboard. “There you go, Ms. Sanders.”
There I go indeed.
While I wouldn’t necessarily consider myself the “average” health insurer, this situation would sound familiar to millions of consumers. The real problem is that there is no “average” health insurance user. We all have different health needs, which means we all have unique health insurance needs. The best way to stay on top of your health and to use your health insurance to the best of its ability is to educate yourself and follow some basic guidelines.
The Consumer’s Guide to Health Insurance
Sifting through health insurance jargon and practices can be challenging for the everyday consumer. Until we fall ill or a billing issue occurs, health insurance benefits and terms aren’t things we really think about. As Vice President of Consumer Marketing for GoHealth, a consumer-focused online health insurance platform, Michael Mahoney has extensive knowledge of health insurance coverage. Mahoney explained that “consumers should understand exactly what [a] plan covers and includes” prior to selecting it. The research into what specific terms mean and what specific options are available to you should start before you’ve officially chosen a coverage provider.
Mahoney stressed the importance of knowing the “copayment amount, premium, deductible, physician network, coinsurance rates, benefit levels, and prescription costs” of the plan you are considering. Specifically, Mahoney suggested paying “extra attention to the premium and the deductible when comparing health plans” because “simply going with the plan with the lowest premium and highest deductible may not be the best game plan for every consumer.” So, in an effort to better understand the troubles I faced with my insurance coverage six months ago and to help guide others in the process, I’ve researched some specific insurance terms.
Terms to Know
- Premium: A premium is the amount of money you pay in return for your insurance coverage. This payment is typically made as one full payment or through several installments during the duration of a policy agreement.
- Deductible: A deductible is the fixed dollar amount you agree to pay for your health needs before your insurer starts to make payments for covered medical services. This dollar amount will vary depending on the insurance plan you choose and there can be separate deductibles for specific services (hospitalizations, surgeries, etc.).
- Copayment: The copayment is the fixed amount you pay when a medical service is received. This cost is shared by the insurer and the insured. You pay an amount upfront for a medical service and your insurer pays the remaining amount which is billed by the facility at a later date. This copayment amount varies among insurance plan agreements and is defined in the plan when an agreement is made.
- Physician Network: The physician network or “in network providers” are the physicians and facilities that are covered by your insurance company. This network of doctors and hospitals is contracted with your insurance company to provide services to you at a discounted rate. The networks will vary among insurance companies and plans. If you receive services from a physician or facility that is not within your insurance’s physician network, that service is considered “out of network” and will cost more.
While these are perhaps the most important terms a consumer needs to know, there are numerous other phrases involved with health insurance that you should educate yourself on. The Bureau of Labor Statistics defines key concepts for both consumers and health care companies and is a good guide for understanding coverage.
On Monday, I’ll explore tools and tips that can help you manage your health benefits.