Finance Assistance

Even if you have health insurance, you could wind up paying large sums out-of-pocket for care should you make mistakes. How to minimize costly errors:

Get pre-authorization.
If you’re required to get an authorization from your plan prior to treatment, be sure you do so. Don’t assume the plan will pay simply because the treatment was medically necessary. Double-check with the treating doctor to make sure that he or she has the authorization in hand.

Seek a referral.
Know whether you have to seek a referral from your primary-care doctor before visiting a specialist. Even if you get the proper referral, any treatments that arise from that visit may still require preauthorization.

Know the limits.
Your plan’s benefits and payments may have limitations. For example, if your plan pays $50 for a visit and you consult a more-expensive doctor who charges $85, you must pay the $35 difference.

Know the deadlines.
If you want to dispute a denial of your claim or the insurer payment, you typically have up to six months. Know the cut-off date—otherwise, you could lose an appeal by missing a deadline.

Know the deductibles.
Understand how much your deductible is and what it applies to. For example, a preventive checkup might be covered even if you haven’t met your deductible, but a subsequent treatment that the doctor prescribes during that visit might not be. Or your plan may cover a visit but not a procedure performed on the same day.

Price the drugs.
To avoid being charged for lots of expensive brand-name prescription drugs, ask your doctor to prescribe an equivalent generic or a less-expensive medication whenever possible.

In the near future, more employers are likely to offer high-deductible health insurance as a plan option—either by itself or coupled with a health savings account (HSA) or a health reimbursement arrangement (HRA). High-deductible health coverage lowers your plan’s cost by requiring you to pay more out-of-pocket for care before coverage kicks in. An HSA and HRA allow you to save pretax dollars in accounts to pay for those costs. Is a high-deductible plan worthwhile? Questions to ask:

■ Will the high-deductible plan satisfy your family’s health-care needs?

■ Are pre-existing conditions covered?

■ Is the plan’s physician/hospital network suitable?

■ Is the insurer financially sound based on data from A.M. Best, Standard & Poor’s, or other ratings services?

■ Is there a cap on how much you will be required to pay in any given year?

■ Once your deductible is met, what percentage of costs will you be required to pay?

Get health insurers to pay more

If you have health insurance, you probably have found that your insurer increasingly isn’t picking up its maximum percentage of charges once your deductible has been met. That’s because insurers pay based on “usual, customary and reasonable” (UCR) charges for and your care may have exceeded their price list. The UCR varies from region to region, and you won’t know how much you’re getting back until your Explanation of Benefits arrives.

WHAT TO DO: If you find a large gap between the doctor’s bill and the insurer’s UCR amount, call other doctors and labs in your area to find out what they charge for the same procedures and tests. Then call your insurer and ask how to appeal its decision, or appeal to your state insurance department. Or inform your doctor about your insurer’s UCR and ask for a price break.