Kids and Health Care: Tricks of the Trade
For some readers, this chapter may have been a review of things they already knew about health care in the U.S. But we're usually surprised by how many people -- including smart, rich ones -- don't know the nuts and bolts of how doctors, hospitals and insurance companies work.
If you're on your own, you can afford this obliviousness. If you have kids, you can't.
To conclude this chapter, we'll consider a few of the tricks, traps and sharp moves that make medicine in the U.S. so complicated. And we'll make some suggestions for how to deal with them.
Trick 1: Insurance companies -- and some providers -- don't really want you to understand how health coverage works.
Most group health insurance policyholders have no idea of their exact coverage limits or rules of their plans until after the open enrollment period when they receive their benefit booklets. And, even then, benefit booklets don't fully describe policy terms. The actual master policies are usually kept at the insurance company, with the broker who arranged the policy or with the HR department of the insured entity.
Solution: Every member of a health insurance group has the legal right to review the master policy. However, the policy owner (the employer or organization) can put various limits on how a member can see the master policy. Most people never ask to read the master policy. If you have kids -- and if the policy is reasonably close -- ask to read the policy. When you do, look for two things: the Declarations Page, which describes the parties to the insurance contract; and, even more importantly, the Exclusions and Exceptions. These say what's not covered. Understand both.
Trick 2: Managed care plans often pad their provider lists -- and providers don't mind. Have you ever tried to switch primary care physicians within a managed care plan's provider network, only to find out with each phone call that many of the doctors named on the provider list are not accepting new patients? Insurance professionals call these listings "phantom networks." They make plans seem larger and easier to use than they actually are.
Solution: Technology can help here. Instead of relying on printed materials, visit your plan's Web site; these usually have more up-to-date listings. Also, work backwards from providers in your area or that you like to plans in which they are active members.
If the providers aren't part of plans available to you, take them plan information and ask them to join.
Trick 3: Cash-flow management 101. Insurance companies and managed care plans intentionally delay paying claims in order to hang on to cash and maximize profits (insurers keep their cash in interest-bearing accounts). Although most states have laws that require prompt payment of claims, those laws usually apply only to claims that don't have any missing or wrong information. Virtually all claims have some sort of technical error.
Solution: Identify a customer-service representative or claims manager -- even before you make a claim -- and keep that person on your speed dial throughout the claims process. If you or your employer used a broker to set up the coverage, that broker can either be the claims point-man...or find you one in the insurance company.
Trick 4: Your doctor may be all too ready to admit he or she isn't calling the shots. When it comes to things like diagnostic tools and the length of a hospital stay, doctors rarely make decisions anymore. Some may act like the call is theirs...but more will usually admit the decisions are out of their hands. They'd rather blame faceless actuaries.
Solution: Hold your provider responsible for the quality of the care he or she provides. Emphasize that you and the doctor are on the same side of the equation. Offer to press any contacts you have at the insurance company or managed care plan to get additional care, if you believe you need it.
Convince the doctor that you're willing to fight for the services you need; he or she will be more inclined to press your kids' case.
Trick 5: Sometimes, managed care plans will try to get members to pay out-of-network charges that aren't the members' fault.
Solution: Question every out-of-network charge you get in the mail. It's not your responsibility to pay the doctor's fee for an out-of-network radiologist who read your hospital x-ray because no network radiologist was available. As a patient, all you can do is select an network primary care physician and network hospital. Other than that, you have no control of who else gets involved with your care within the hospital setting.
If the plan tries to force an out-of-network fee on you, file an official complaint with your state insurance department, and then ask the department to investigate the plan's billing history.
Trick 6: Insurance companies, managed care plans and some providers hide behind UCR fee schedules. The groups will argue -- sometimes within the same claim cycle -- that UCR fees are both too high...and not high enough. And then, if you challenge the settlement, you find out that the details of UCR fees are usually kept secret (as "proprietary" business information).
Solution: Fight a two-front battle. If your providers charge more than UCR fees, pressure them to accept the UCR fees as full payment. Many will -- even if they start out billing more. At the same time, use the threat of a complaint to the state insurance regulators to pressure the insurance company or managed care plan to reconsider its UCR fees. This last step is a long shot...but it plays off of the last trick.
Trick 7: Insurance companies and managed care plans will do everything they can to keep complaints and grievances within their internal review and appeals processes. They don't like to admit -- as they are required by law in many states -- that external complaint channels exist. These external complaint channels usually involve the state insurance department.
Solution: See Appendix A. And let your contact at the insurance company or managed care plan know that you have the insurance department's number. In most cases, insurance regulators are bound by law to investigate all consumer complaints that fall under their jurisdiction.
