Getting the Most Out of Your Health Plan

Submitted by SharpHealth Team on Monday 11th October 2010
In this article
  • How to choose a health plan that works for you.
  • How to get your bills paid.
  • What to do if the bills keep coming.

The health insurance game is complicated. HMOs, PPOS, private plans and COBRAs; how does a SharpMan make sense of it all? Moreover, should you actually need to see a doctor, how do you keep the bill collectors from coming after you when you know you’ve already paid the bill? Check out these SharpMan tips for keeping healthy with health plans:

Choosing a Plan

When starting a new job or during the "open enrollment" period of your current job, remember that you have a choice. Not all health plans are the same.

A Health Maintenance Organization, or "HMO",for example, is a plan that employs a group of doctors to service the health needs of its members. You’ll be assigned a primary physician who will be your "first stop" whether you need a dermatologist or a neurosurgeon, and based on this primary physician’s discretion, you will receive a referral that allows you to go to the required specialist. While this seems like a hassle, the upside is that you pay no bills other than a small "co-payment," usually $10-25 — all other health service costs are handles by the HMO. The downside? HMOs require a lot of legwork. Whether you’ve got a pimple on your nose or a tumor in your brain, you must see your primary physician for the referral. Many members report that actually getting the referral is difficult, since it is the job of the primary physician to manage member costs by determining need. Another downside is that you must see the doctors who work for your HMO in order to get the full benefit of the plan.

By contrast, a Preferred Provider Organization, or "PPO" is a health plan that affiliates, rather than employs, a group of doctors. Doctors choose to be "providers" of health services for PPO members, and agree to charge certain fees for services rendered to PPO members. When you require a doctor’s attention, you needn’t go to a primary physician for a referral. Instead, you determine which doctors or specialists in your area are PPO providers (usually listed in that PPO book you stashed away when you signed on). PPOs usually have a "deductible" — an amount of money you must pay out-of-pocket before the plan begins paying your bills. If you have not "met" or spent your deductible in a given year, usually $150-2000, you will be billed the full amount of the doctor’s bill until you have spent an amount equal to this dollar amount. Once your deductible has been met, depending on your plan, your will be responsible for either a pre-determined co-payment or, alternatively, 10-20% of the cost of your visit. The remainder of your bill is paid by the PPO. Should you decide to see a "specialist" or other doctor outside of your PPO’s network of providers, the PPO will likely pay some portion of the bill, anywhere from 40-80%. The remainder is your responsibility. In the event that you go outside the plan, you may be required to pay for services up front and seek reimbursement from your PPO. A hassle. The upside, of course, is that you have the freedom to see whomever you please, and are never required to get a primary physician’s referral.

Private insurance and Consolidated Omnibus Budget Reconciliation Act, or "COBRA" (where your employer is legally required to help you obtain insurance for a period of time after you leave your job) plans are often variations on the HMO and PPO themes.

How do you choose? The answer lies in knowing yourself. Do you see a lot of doctors? Do you see them often? Do you have a regular physician that you’d like to stay with? If you’re prone to illness, chances are an HMO may be more of a hassle than a plus. On the other hand, if you never become sick, an HMO may be the low-cost option for you. Finally, if you know you’ll require the services of a physician in the near future, (for example, if your SharpWoman is having a child) you may feel more comfortable having the option to choose your physician.

SharpMan Tip:

If you choose a PPO and avail yourself of the option of seeing out-of-network physicians, consider putting pre-tax dollars aside for the purpose of paying medical bills. Many employers, particularly larger ones, allow you to segment a portion of your pre-tax earnings in order to pay these bills. The downside? Any funds unused for this purpose by the close of the calendar year are forfeited, so budget conservatively.

Seeing Your Doctor/ Getting a Bill

If you see an HMO doctor or a PPO provider, the bill will be sent directly to your plan. Nonetheless, always ask for a receipt, often called a "superbill," to document the services received. You may receive a bill from your doctor in the mail. Don’t pay this bill until you receive a statement from your insurance company enumerating the bill they received and how much was paid. If the two bills match up and there is an unpaid balance labeled "patient’s responsibility," pay this amount to your doctor. If there is a discrepancy between what was billed to you and to the insurance company, immediately report the error to your insurance company.

Many times, even an out-of-network doctor may "courtesy bill" your insurance, but don’t count on it. When this occurs, the doctor’s office will forward the bill to your health plan, but you may still be expected to pay for services before leaving the office. Make a point of inquiring when you make your appointment.

The Follow Up

Many people report horror stories about dealing with bills from medical professions. Why is this? Frequently doctors in medical practice — who are usually not trained business people — will outsource their billing needs to a professional billing service. Sometimes these billing services are paid based on the amount of receivables they collect. Watch out. Often these services will accidentally double bill, or bill for services that were never provided. Or, while you wait for the statement from your insurance company, the billing service will forward your account to their collections agency, so that even if you send them payment, you will continue to receive harassing mail. Protect yourself: always request a copy of your superbill indicating what services you received. Compare the superbill, the doctor’s bill and the insurance statement and retain these along with payment information — all in one file. Watch credit card statements for double-billing and report problems immediately. This way, should a problem arise — and it probably will — you’ll have all of your supporting paperwork in one place.

Got questions on this SharpHealth topic? WRITE SHARPHEALTH.

This article last updated on Monday 11th October 2010
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