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Echo Focus: System navigation

February 17, 2011

By Staff Reporter

Unfortunately, to avoid pricey bills you will likely lay out thousands of dollars in advance of ever actually requiring a costly procedure done. Perhaps it is best to look at it as good luck towards never need anything, and something that’s good to have. In the meantime, one of the most important things you can do is to understand your policy. Last week, the Irish Echo uncovered ways to get insured, including for those who are undocumented, unemployed or in a service industry and for those who simply cannot afford it.
Once you have procured some form of coverage, the best way to stay in good form is to understand what your policy covers. While one has to cut through a lot of industry jargon, sometimes that can work for you, especially in getting covered for things you may not be outright insured for. The insurance companies, after all, want to avoid an expensive treatment as much as you do.

Terms and conditions
Co-payment, rider, PPO, HMO – it all sounds like another language, and in essence, it is. While many Americans get their first taste of insurance from their parents’ policies, lasting through 19 years of age, many people still don’t understand what insurance entails. And when making your own choices, it helps to have an understanding of what the terms that explain your benefits mean.
For instance, a co-payment is the money you will have to plunk down at the time of visiting a doctor’s office or emergency room (though the latter you are most likely to be billed for). Depending on your plan, it can range from $5 to over $25, but it generally a small price to pay when visits can cost on average $125 with no insurance.
The deductible is the amount you pay out-of-pocket for medical care before the insurance comes in. If you are insured through your job, the amount is usually taken out of your paycheck, but a private plan will bill you for a certain amount, determined by your medical history and that of your family. If you are paying out of your paycheck or your employer covers all expenses, that amount is called the premium.
Another “co-” is coinsurance, which is simply the difference from what your deductible pays for and what insurance will cover in a fee-for-service situation, such as an operation. Usually in the form of a percentage, for example, if the health insurance company pays 80 percent of the claim, you are expected to pay 20 percent.
Covered expenses are — you guessed it — those covered by the plan. Some do not pay for things like prescriptions, mental health or dental, and they should be explained in your policy literature. As daunting as that packet is, it is worth a thorough read, especially when you are considering having a medical procedure or going to a new doctor or specialist.
What determines the charges are what insurance companies call a reasonable and customary fee for a particular service. This depends on geographic location, your health and the service rendered. For instance, if your doctor charges $5,000 for knee surgery, and most other doctors in the area charge $4,600, that $400 difference will have to come out of your pocket. The insurance company has actuaries working to know what things should cost, and unless your doctor is willing to accept the insurance payment as full payment, which is worth asking about, you will be responsible. This is in addition to any coinsurance and deductible you are paying as well.
Something that can throw a wrench into coverage will be what companies call pre-existing conditions. If they find that you have a torn-up knee from playing football long before you were insured, you might have a hard time getting covered for that knee surgery.
Aside from all the possible ways to charge the insured money, there are benefits, literally, to having health insurance. You will usually be able to choose a primary care physician or PCP, who will be your first stop for medical issues, barring emergencies.
Many insurance companies require a referral for you to be covered for a visit to a specialist, such as an orthopedist or an allergist, and you would first need to see your PCP and get the referral. It is good, however, for the PCP to have on record what is ailing you and when, so they can keep accurate records.
Another thing that puzzles, and can determine who your PCP will be, is the difference between PPOs and HMOs. An HMO (Health Maintenance Organization) is a
prepaid health plan. You would pay a monthly premium and get covered for doctors’ visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and any possible therapy. The downside is that you must use the doctors and hospitals designated by the HMO.
A PPO (Preferred Provider Organization) is a combination of fee-for-service and an HMO structure. When you use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered. While you can use other doctors, it will come at a higher cost.

To HMO or not?
This is where that thick book that lists doctors available to you will come in handy. Unless you are given one with a private health insurance, it can usually be found at work. Use this as a reference for what doctors are available to you, depending on your HMO or PPO, and keep in mind some doctors change often. Calling ahead to see if your insurance is accepted is always a good idea.
While many doctors will bill your insurance company for visits and care directly, there are cases when doctors expect to be paid in full at the time of visit and expect you arrange reimbursement yourself. Find out how the doctor you prefer handles this.
The best way to get your health insurance working for you is to stay informed. Reading material, especially periodic letters from the insurance company explaining changes to your coverage, is important.
There are ways to get your provider to do a little more for you than just collect and reimburse money. Many companies have come to realize the importance of something called “preventative care,” which can save thousands in the long run. Covering things upfront can keep from larger bills in the long run, and less money for you and your insurer. Regular screenings, such as Pap smears and colonoscopies can also be covered.
Some plans will pay for monthly gym memberships, provided you go a certain number of times a week (what they consider will be enough to keep you healthy). You might have to lay out the money at first, but any gym should be able to give you a printout of your visits that your health insurance company will use to reimburse you for. The amount varies, and not every company does it, but it is the idea exercise will ward off expensive maladies, such a diabetes and heart disease. Some companies also cover dental cleaning visits to prevent disease down the road.
Other things you can do to keep up on things is to read the monthly newsletter which often accompanies a policy, talking to your doctor at length and insisting on clear answers and explanations, and making sure the insurance company will keep your informed of changes in your plan.
It is impossible to cover every aspect of health insurance, but the basics are broad enough to look into if you have care. It is wise to look into hospital specifics, such as if you are locked into a certain hospital network, or weather or not urgent care is covered under your plan as well.
If something is not right and you have a complaint about the insurance or service you have received, you should make a concerted effort to keep records of all correspondence, bills, and phone conversations you have.
For insurance, at least, a lot of work will go a long way.

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