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!

Top 10 Reasons Your HSA Does Not Match Your Deductible #2

2. Your medical claims have not been submitted to your insurance.

Just the other day, I went for a follow up appointment for an ankle fracture from a few months ago. While checking out, the billing representative for my physician asked me if I would like to go ahead and pay for today’s visit. Confused, I asked if she had already submitted the claim to my insurance for processing. She told me that since I have a high deductible plan, she could go ahead and see what the pay schedule is for the visit so that I could pay in full now, and they would submit the claim later. I kindly declined and explained that without having submitted my claim to my insurance and receiving confirmation of how much I would owe on an EOB statement, I would prefer that I not pay at this time.

This is not an uncommon scenario of how HSA accounts and medical deductible can become unbalanced. Since claims do not always process in the order of the dates of service (usually they just process in order of how they are received), I could meet my deductible before this claim is ever sent to my insurance and not owe anything out of pocket for my visit. Or the billing representative could mistype when submitting the claim, and my claim might never process and go to my deductible. Although I would have paid for a medical bill, if the claim never processes through my insurance, it will not be applied to my deductible.

For instance, let’s say that I started the year with $2000 in my HSA and a $2000 in network deductible. I have some claims totaling $1500, all of which process to my in network deductible, and I pay out of my HSA. I now have $500 in my HSA and left to meet with my deductible. Then, on a Monday, I slip and fall. I go to the emergency room and get x-rays. It’s a break. They submit my claims for processing to my insurance. On Wednesday, I go to an orthopedic specialist to get my new crutches, walking boots, and to check on the fracture. While checking out, the provider asks if I would like to go ahead and pay the $250 bill, which is the contracted rate with Anthem. They called and checked with my insurance, and I still owe $500 to my deductible. I decide I would rather pay now and use my HSA. Since this has not yet processed through my insurance, I now have $250 in my HSA and $500 to meet on my deductible. On Friday, my insurance processes my claims from the emergency room. They total $1000, so they pay $500 and apply $500 to complete my deductible. I receive the bill for $500, but I only have $500 in my HSA. The orthopedic specialist forgot to submit my claim, so now I have a $250 out of pocket expense to pay my emergency room bill until my orthopedic specialist can submit the claim, have it processed, get paid in full, and refund me the payment that I made during the visit.

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!

Top 10 Reasons Your HSA Does Not Match Your Deductible #3

3. You put a deposit down for a procedure and are owed money back.

The growing trend of consumer driven health care has meant changes for the benefits offered to employees (higher deductibles, HSAs, FSAs, and HRAs). Those significant changes have also meant changes for providers. Higher deductibles mean that many providers will not receive any payment from insurance companies if deductibles have not yet been met, as the responsibility will be on the patient. With procedures that can easily go above and beyond a member’s high deductible, some providers are beginning to require deposits to be put down before they will perform surgeries or other costly procedures for members with high deductible plans to ensure that they will receive payment. Some members choose to use their HSA funds to pay for these deposits, and if their claim processes so the member’s responsibility it less than the deposit they made, the member’s HSA and deductible will be un-even until the provider gives the member the refund that they are due.

For instance, let’s say that you have a $1000 deductible and start the year with $1000 in your HSA. You go to the hospital because you are having stomach pains. After a day of observation, you doctors have decided that you need surgery. The surgery is expensive, though, and to ensure that they receive payment, the surgeon requires that you pay a $500 deposit. You pay this out of your HSA, leaving you with $500 in your HSA and $1000 deductible to be met since no claims have been submitted yet.

Your claims from the hospital are submitted to the insurance first and total $1500. Your insurance processes this, applies $1000 to your deductible, and pays the remaining $500. Then, your surgeon submits her bill to your insurance for $10,000. Since you have already met your deductible and do not have any co-insurance due, this claim is paid in full by your insurance and you do not owe anything. However, you now receive a bill from the hospital for $1000 and only have $500 in your HSA. Everything has been done correctly by insurance, but now that your surgeon has received payment in full for your claim, you are owed $500 back from the deposit you put down. Once those funds have been returned to your HSA, you will have $1000 in your HSA and can pay in full your responsibility to the hospital for $1000.

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!