Top 5: Ways to Control the Cost of Healthcare #5

5. Get pre-authorizations or predeterminations of

benefits done when necessary

Pre-authorizations are prior approval from an insurance carrier for a procedure. These are not guarantees that the claim that comes in will be covered, but it is a statement that the insurer intends to cover the service. Many non-emergency medical procedures and services require a pre-authorization, and it is important to ask your physician if a prior-authorization is needed before a procedure. Most physicians will be generally aware of procedures requiring a pre-authorization, and they will call into the insurance carrier for review. Without a pre-authorization, some claims that might have been covered will be denied. If you want to be certain that a procedure does or does not require a pre-authorization, you can always get the procedure coding from your provider and call them in to your insurance carrier to verify.

Predeterminations of benefits are similar to pre-authorizations, but they are not required. Often, they are done for procedures in which a provider must prove that a patient meets medical criteria for a procedure before it can be performed. For instance, treatment of varicose veins is often denied as not medically necessary. However, if a physician does a predetermination of benefits with the insurance carrier and can provide documentation proving that the member meets the medical criteria, the procedure could be covered.

While it is always important to consider your health and the advice of your physician first, you can also help to control the cost of your healthcare by ensuring that the necessary steps (such as getting a pre-authorization or predetermination of benefits) are taken before any major procedure.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #4

4. Ensure that your lab work is being completed by an in-network/participating lab

Just like in network providers, it is important to utilize in network (or participating) labs in order to receive the highest benefit from your medical coverage. Just like going to an out of network provider, using an out of network lab can result in higher costs, balance billing, and claims going towards a higher, out of network deductible.

For instance, let’s say that you have the following benefits and have already met your in network deductible for the year.

Covered Benefits	Network	Non-Network
Deductible (single/family)	$500/$1000	$1000/$2000
Out of Pocket Limit (single/family)	$3000/$6000	$6000/$12000
Preventive Care Services Services include but are not limited to: Routine exams, pelvic exams, pap testing, PSA tests, immunizations, annual diabetic, eye exam, vision and hearing screenings ·         Physician Home and Office Visits (PCP/SCP) ·         Other Outpatient services @ Hospital/Alternative care facility	$25/$50 20%	40% 40%

You go to your physician for your annual preventative visit. You have run a check on your insurance carrier’s website, and you confirm that your physician is in network. During your annual preventative exam, your physician runs some bloodwork and sends it off to their lab. Your physician’s bill processes through insurance, and since you have already met your in network deductible, you only owe a $25 copay.

However, your lab work was sent to an out of network lab. They bill $100. The contracted rate for these services is $50, and your insurance carrier applies this to your out of network deductible, which you have not yet met. Since the lab is not contracted, they are able to balance bill, and you are responsible for $100.

Had you requested that your physician send your lab work to an in network lab (which you can find a listing by doing an search on your insurance carrier’s site), then the lab work would have been adjusted to the contracted rate of $50, of which you would have only been responsible for 20% (or $10 – a difference of $100 for you).

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #3

3. Opt for generic or lower cost drug alternatives when available

Many factors play into the costs of prescription medications: cost of ingredients, costs of research and development, patents, etc. Often, brand name prescriptions have an initial higher cost for healthcare consumers to offset the cost of developing the medications during the window of time when their patent allows for the company to have control over the distribution of the medication. After this time, other companies can create generic alternatives to the brand names.

As the US Food and Drug Administration states:

Generic drugs are important options that allow greater access to health care for all Americans. They are copies of brand-name drugs and are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use.

Health care professionals and consumers can be assured that FDA approved generic drug products have met the same rigid standards as the innovator drug. All generic drugs approved by FDA have the same high quality, strength, purity and stability as brand-name drugs. And, the generic manufacturing, packaging, and testing sites must pass the same quality standards as those of brand name drugs.

Since the companies creating the generic medications do not have to invest as significantly in the research and development of the medication, they can sometimes offer it at a discount rate.
While your primary decision on medications should be the advice of your physician, opting for generic or lower cost drug alternatives is another way to control the cost of your healthcare, and you can ask your provider about your options.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #2

2. Choose the right care facility (Primary Care Physician vs. Urgent Care vs. Emergency Room)

There are lots of options when it comes to where you go to receive health care services, and those options have different purposes as well as different financial implications.

Duke Health offers the following explanation of when to use each type of health care service:

Primary Care Provider

Unless you are experiencing a life-threatening emergency, primary care centers are the best places to start. Primary care providers are physicians who deliver basic care for common illnesses. They are your first stop for most undiagnosed health concerns.

You should visit a primary care center for illnesses such as colds, flu, and sore throats; minor injuries, aches, and pains; or routine health exams. You can schedule appointments with primary care providers during the week, and they are available by phone anytime for advice about health problems.

Urgent Care Center

If your primary care physician is not available and you need quick medical attention for a non-life-threatening problem, visit an urgent care center. Urgent care centers have similar resources to primary care facilities, but they provide comprehensive quality care on a walk-in basis with extended hours.

Go to an urgent care center when you need immediate medical attention or have non-emergency health concerns after hours. Examples include ear infections, sprains, simple cuts and burns, and eye injuries.

Emergency Department

Life-threatening emergencies and late-night trauma require an immediate visit to the hospital. Emergency rooms offer inpatient care, emergency services, trauma services, and more. Emergency clinicians are able to recognize, diagnose, and make recommendations for a wide array of medical issues.

Call 911 or drive to the emergency department at your nearest hospital whenever conditions cause severe symptoms and/or put your health at serious risk. Examples include heart attacks, poisoning, severe bleeding, and broken bones.

While life threatening emergencies require a visit to the emergency room, other illnesses or injuries do not and can offer significantly lower cost options for care.

For instance, let’s say that your benefits are as follows and you have already met your deductible year to date:

Top 5: Ways to Control the Cost of Healthcare #1

1. Utilize in-network/participating providers with your plan

Most insurance carriers create ‘in-network’ or ‘participating’ provider groups for their plans. These are providers that meet certain criteria and contract through the carrier to accept certain pay rates for their services. By going to an in-network or participating provider, you can help to control your healthcare costs and ensure that you are getting the highest possible benefit for your care.

For instance, if a provider is in-network for your plan and they bill $100 for an office visit but your insurance carrier has a contracted rate of $75, you will only be billed for $75, which will be applied to your deductible. However, if you were to go to a provider for the exact same service and they bill $100 but are out of network you will still owe $100 because they are not contract to accept the $75 rate. Additionally, only $75 will go towards your deductible. This is called balance billing, and if there is no agreement between the insurance carrier and the provider, the physician is allowed to bill you whatever amount they choose to charge.

Also, some plans are set up to have different deductibles for in and out of network claims. For instance, your benefits summary might look like this:

Covered Benefits	Network	Non-Network
Deductible Family coverage requires the family deductible to be met before coinsurance applies. The single deductible does not apply to family coverage. Network and Non-Network deductibles are combined.	$1000 individual $2000 family	$2000 individual $4000 family
Out of Pocket Maximum	$1000 individual $2000 family	$2000 individual $4000 family

Let’s say that these are your benefits and you go to an in network emergency room because you are having chest pains. After the visit, testing, and discharge, you are billed $3000. You provider adjusts this to their contracted rates for your services to $2000. Since you have individual coverage and no coinsurance after your deductible, you will owe $1000 to meet your deductible, $1000 will be paid by the insurance carrier, and $1000 will be a contracted write off for the emergency room. However, had that emergency room been an out of network facility and you were billed $3000, the insurance company would have applied the full $2000 of the contracted rate to your higher out of network deductible. Since this facility is not contractually obligated to accept their pay rate for the services, you will owe to full $3000.

In order to make sure that you are going to a participating provider, it is best to call the number on the back of your ID card or search your carrier’s directory for participating providers on your plan. If you are asking your provider, it is important to specifically ask whether or not they are contracted with your insurance carrier on your specific plan.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare

Healthcare can be expensive, whether you are on a high deductible health plan with an HSA, a PPO, or some other health care plan. As many plans are becoming consumer driven, it is important as a consumer to understand how to control the costs of your care.

While not every option works best for every person, the top five ways to control the cost of your health care are:

1.    Utilize in-network/participating providers with your plan

2.    Choose the right care facility (Primary Care Physician vs. Urgent Care vs. Emergency Room)

3.    Opt for generic or lower cost drug alternatives when available

4.    Ensure that your lab work is being completed by an in-network/participating lab

5.    Get pre-authorizations or predeterminations of benefits done when necessary

Check back to our blog often over the next few weeks for articles explaining how each of these options can help in controlling the cost of your care. Also, download our Top 5 Ways to Control the Cost of Healthcare checklist!

Got Why?

At McGohan Brabender, we do things differently. We want to be more than your insurance broker. We want to be your trusted resource and empower you, your employees, and your company to live healthier and longer. Our mission is to:

'Generate perpetual vitality by empowering people and organizations to invest in healthier living.'

As a part of this mission to be a resource for our clients and empower them, we would love to hear your benefits questions that you would like to see addressed on this blog!

Please send your questions to kluongo@mcgohanbrabender.com with the subject: Blog Question. Nothing is too small or big, and we will do everything that we can to ensure that we are offering all that you hope to find on this blog.

Thank you for your feedback!

FAQ: I have exhausted all appeals options through my insurance carrier. Is there anything else that I can do?

Medical benefits are not an exact science, and sometimes it is necessary to appeal the processing of your claims with your insurance carrier. Should you receive a denial to your claim from your insurance carrier, exhaust all appeals processes with you insurance carrier, and still believe that your claim should be reprocessed, you are able to appeal through your state’s department of insurance.

The Ohio Department of Insurance is able to provider consumer information and can investigate complaints involving insurance companies and agents. As noted on their site, the department cannot:

·         Act as your legal representative, or give you legal advice

·         Recommend insurance companies or HMOs

·         Force a company to give you what you want if no laws have been broken

·         Make determinations about medical necessity

·         Address problems with your employer's self-funded health plan, unless the plan involves an insurance company, an HMO or an independent administrator that is licensed with the Department

If you have exhausted your appeals process with your insurance carrier and choose to appeal through the Ohio Department of Insurance, you can do so by completing the following complaint form and submitting it per the instructions provided by the ODI.

Consumer Complaint Form

Top 10 Reasons Your HSA Does Not Match Your Deductible #1

1. Your prescriptions have not be submitted to your insurance

One of the most common reasons that HSA accounts do not match up with medical deductibles is because a prescription has not been run through the insurance (and therefore not applied to the deductible) but paid for with HSA funds. Whether a pharmacy has old insurance information, offer a cheaper generic alternative that is not submitted through insurance, or confuse running an HAS card (that has the insurance emblem on it) as running the charges through insurance, our team is seeing this as a common reason that deductibles and HSA accounts become uneven.

For instance, let’s say that you have a $1500 deductible and start the year with $1500 in your HSA account. You fall ill one evening and go to the hospital. The hospital examines and treats you, releasing you the next morning with even medication for a week. However, you have instructions to go get more medication once you are out. The hospital submits the claim for your visit and medication, and it processes towards your in network deductible for $1400.  You go to pick up your prescription, which your pharmacist tells you will cost $150. You pay with your HSA funds, leaving you with $1350 in your account, and go on your way. The next week, you receive the bill for the hospital stay. The bill is for $1400, but you only have $1350 in your account. It seems that your new pharmacist forgot to run your prescription through your insurance, leaving you with uneven HSA funds and deductible.

You go to the pharmacy and ask the pharmacist to reprocess your prescription through your insurance. They resubmit it, and find that you only owed $100 to meet your deductible. They refund the extra $50 to your account, leaving you with $1400 in your HSA. You are now able to pay for your hospital bill in full and have met your $1500 in network deductible.

Want to know to rest of the top 10 reasons your HSA does not match your deductible? Check out the McGohan Brabender checklist and look for upcoming and previous articles explaining the other reasons!