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Avoid Insurance Surprises During Open Enrollment

By Angela Wilson Pennisi, PT, MS

Fall has arrived and with it, open enrollment for most insurance plans.  Patient out of pocket health care costs increased by 11% last year, and from our experience in 2018, this trend shows no signs of slowing.  Avoid unpleasant financial surprises by reading the fine print on the plans you are considering and asking targeted questions before you make your decisions for 2019.


Deductible:  The amount you have to pay before your insurance company pays any benefits.  May be waived for services that have a copayment, such as annual check ups.  Many policies have separate deductibles for in and out of network providers and may also share a larger deductible across a family policy.

Coinsurance:  The percentage of each bill that you must pay.  For in-network providers, you are responsible only for the percentage of the negotiated amount that in-network providers have agreed to accept.  For out-of-network providers, the coinsurance will typically be a higher percentage and is a percentage of what the provider bills.

Copayment:  A set fee per service that the patient is responsible for and must be paid at the time of service.

Out of Pocket Maximum:  After your health care costs reach this level, the plan will pay 100% of health care costs for the remainder of the policy year.

Narrow Networks

A plan might sound great — no deductible, $10 copayment, reasonable premium.  What could be better?  Make sure you read the policy details and understand exactly what types of requirements these plans have to access your benefits.  Many plans will limit you to providers on a short list or limit you to accessing care only at specific hospital systems.  Before you sign up, make sure you not only look up all your providers, but also ask your regular providers whether they intend to participate in 2019.  If your preferred providers don’t participate, any savings might evaporate with increased out of pocket costs.

If your provider doesn’t participate, consider that they may have opted out because these plans deliver these savings by paying providers very low rates, which then require the provider to see many more patients to make the same amount of money.  Ask yourself whether you need more personalized attention that may not be able to be found through an extremely low cost plan or whether the savings will allow you to pay more to see an out of network provider in certain situations.

Calculate Your True Costs

Health care costs can have a huge impact on your household budget, so take the same time you commit for retirement planning or deciding whether you can afford a certain house payment before making a decision.  Look back over the past year or two — how often did you go to the doctor, how many medications do you take, and what were your out of pocket costs?  If you are healthy and go only for annual checkups, a higher deductible plan might be a great fit.  However, make sure you budget some money for that deductible in case of unforeseen expenses.  A health savings account is a great place to set aside pre-tax dollars and for that money to grow tax-free year to year if you don’t use the funds.  Consider the cost of the premium, the deductible, coinsurance and copayments, whether annual checkups are covered without application of the deductible, and whether you might use out-of-network providers under certain circumstances when calculating your true health care costs.  Finally, consider the time-cost of a plan that might come with a lot of administrative burden, such as ones that require preauthorization for many procedures or plans with insurance companies that have a reputation for putting up barriers to paying the bills.  If you have to spend hours on the phone resolving claim issues, you  must consider the cost of that time, as well.

Medicare Advantage Plans

There has been prolific growth in Medicare Advantage plans in recent years as patients are lured by lower premiums and out of pocket costs.  However, be aware that a name brand Medicare Advantage plan is not the same as having a name brand commercial policy.  Plans are frequently more restrictive and create more administrative burden for both the patient and provider.  Regular Medicare Part B coverage generally offers reasonable payment and hassle-free claims processing for most procedures.  While any federal program comes with its own set of regulations and requirements for your providers, providers are familiar with them and used to complying.  Medicare Advantage plans all have different rules and guidelines that may be difficult for you and your providers to stay on top of.  For more information, read on to learn about preauthorization and utilization review.

Preauthorization Requirements and Utilization Review

When you select a health care plan and review the coverage information, many patients consider whether they are covered for a certain number of visits in a year’s time.  However, in an effort to control health care costs, many insurers have contracted with outside companies to manage the preauthorization process or to retrospectively review charges for medical necessity (and request a refund!).  Unfortunately, the plan you chose that allows up to 80 physical therapy visits, may end up only approving 6 or 8 visits as medically necessary, whether you and your provider agree or not.

Additional problems arise when providers and patients are given different information from the insurer than they are given from the outside preauthorization contractor.  For example, the insurer may advise you that preauthorization is required, but when the provider submits for preauthorization from the outside contractor, he or she is advised that it is not required.  How the claim ultimately ends up processing is anyone’s guess, but many he said/she said phone calls may be required to get around the insurance company’s efforts to pass the buck!  As you review materials for open enrollment, talk directly with your human resources staff, as well as call the insurance company you are considering directly for more information about what types of procedures will require pre-authorization.

If you select a plan that requires additional authorization beyond your physician’s or physical therapist’s recommendation, be prepared to take names and reference numbers for every interaction to ensure your documentation is in place in case you ever need to demonstrate that you attempted to obtain preauthorization but were advised it was not required in this case.

Final Thoughts

As you navigate open enrollment, remember that the insurance company is trying to sell you a policy and that you may need to read between the lines to really understand the potential limitations and how they might affect you.  I’ve often advised patients that insurance companies have perfected behaving like the “children of divorced parents,” telling one parent (the patient) exactly what they want to hear and blaming everything on the other parent (the provider or the utilization management contractor for example).  When your insurance company tells you that your provider doesn’t know how to file a claim properly or that you don’t owe your provider for a service that was provided in good faith for your benefit, take it with a grain of salt and be empowered to advocate for yourself to access the benefits for which you have paid.

Angela Wilson Pennisi is president of PhysioPartners, with locations in Lakeview and the Loop in Chicago.