Avoiding Health Insurance Claim & Private Health Insurance

By: Ryan Patterson

Unfortunately, paying for health care these days - whether it's hospital care, group or private health insurance, or durable medical supplies - is a lot like buying a car: You gotta haggle. If you can research and take care of your out-of-pocket expenses prior to surgery, it's possible and wise to negotiate with the hospital and providers for a lower out-of-pocket rate.

For example, say you know you have elective surgery coming up, and you've discussed it with your doctor and agreed on a date. His office already has the paperwork process underway with the insurance company, and you read through your policy and find that it does not cover out-of-network anesthesia. What do you do? You might call the hospital and ask how many in-network anesthesiologists they generally have on hand at the time when you've scheduled your surgery. If you know there's a good chance the person who is going to provide that service is not going to be covered by your policy, this is where the negotiations start.

Today, we have to negotiate these kinds of things, as difficult as that seems in light of any health issue. We also have a growing rate of tiered billing practices, so we can be charged anything from what a provider like Medicaid or Medicare might have to pay, to the price level of an uninsured patient, which might be substantially higher, but since the charges aren't necessarily standardized, there's a lot of room for discussion. Many hospitals charge uninsured individuals a lot more for services so they can make up for costs lost elsewhere in their operations. The point is, from one end of that spectrum to the other, there's a lot of negotiation room. Knowledge is power, especially in this scenario.

Start with reading and digesting your health insurance policy, whether it is group, government provided, or private health insurance. Call your doctor and ask what kinds of surgery-related expenses a patient is generally expected to cover. These may include radiology (x-rays), consultation with out-of-network specialists (whose fees are also negotiable), pathology, and even blood transfusions. Then, starting with the finance department, call the hospital and ask them which service providers operate outside of your network, and get ready for the talks to begin.

Explain what your insurance provider will cover and what you can afford to pay for the rest. Many hospitals today have made their pricing policies transparent and therefore have prices posted to the hospital Web site or readily available for consumer perusal. Keep in mind that the hospitals offering such practices also only guarantee the prices from the date of printing (or publishing); all the same, armed with this information you can at least get a rough idea of the price range you're dealing with.

According to one lawyer at the Texas State Department of Insurance, pricing is not the only thing you can tweak. "You can also talk to your own doctor and see whether he can find other providers at the hospital who wouldn't be out-of-network. If you have one surgery date, but that scheduled time doesn't coincide with the physical presence of in-network providers, but another time does, well, you'd choose a different time, wouldn't you?" He also said to be on the lookout for words like "allowable," "usual," and "customary" in your policy, because those usually signal "points of flexibility," and we could all use a little flexibility with insurance companies and hospitals.

Health Insurance
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