Many people believe their health insurance carrier is in their corner, but unfortunately, that’s not usually the case. It can be confusing to figure out the realities about health insurance, especially when big companies hide the truth about the costs of care or about coverage details.
Not reading the fine print could turn out to be a huge money mistake, so be sure you know the details of what your insurance should cover and how to save as much as you can when getting medical services. It's up to you to be an informed consumer — here are nine truths your insurance company doesn't want you to know.
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Full coverage doesn't always mean all your costs are paid for
Some insurers market plans as "full coverage" plans. But this doesn't necessarily mean every single cost you could incur is covered.
You may have limited or no coverage if you see an out-of-network provider (a provider who hasn't agreed to participate with your insurer). Some services may be excluded entirely. And even with covered services, there will usually be copays and coinsurance costs to pay.
Be sure to check the coverage details carefully — including looking for any potential exclusions and checking your out-of-pocket spending limit — to make sure you know how much of your healthcare costs you could be responsible for.
Billing mistakes happen all the time
One of the most surprising things patients learn is medical bills can contain errors or overcharges, and more often than they think. These errors can include:
- Billing the wrong code, which means you get charged for the wrong services
- Unbundling codes, which means instead of charging for one global service, they break down the service into all its parts so you pay more
- Upcoding (charging for a more expensive service)
When these errors occur, you could end up paying more money since you're usually responsible for covering at least part of the costs of your care. To avoid this, review your bills carefully and ask questions about exactly what services you were charged for if you don't understand.
Balance billing can cost you
Balance billing is a common practice. It occurs when an out-of-network provider bills you for the difference between what your insurer pays for a service and what the provider charges for it.
Often, providers — and especially hospitals — charge inflated prices for minor things such as bandages or even Tylenol. The insurer pays only a small portion of this and you're left stuck with the remaining cost of the inflated bill. To avoid this, request an itemized copy of your bill, review it carefully, and question any charges that seem needlessly inflated.
Not all caregivers are covered, even in in-network facilities
As an insured patient, if you visit a hospital or doctor's office that is within your insurance network, it stands to reason that all the care you receive would be in-network, right?
Unfortunately, that's not necessarily the case. Some providers at the office or hospital, such as radiologists, anesthesiologists, pathologists, and surgeons, may be out-of-network, even if they perform services at an in-network facility. You could end up owing a fortune for the services they provide, since out-of-network care is typically much more expensive and often not fully covered.
To try and avoid this, be sure to ask at your doctor's office or the hospital if each person you are working with is in-network. If the situation is an emergency, this may not be possible — but your insurer should cover the costs of emergency care, even from non-network providers.
Insurers often deny legitimate claims
Insurers are in the business of making money, and paying expensive claims interferes with that. As a result, it's common practice for insurers to deny legitimate claims to see if they will get away with it. In fact, in one study of Medicare Advantage Organizations, insurers ended up overturning as many as 75% of denials once beneficiaries or providers appealed them.
Make sure that you know exactly what your insurance covers and work with your provider to appeal a denial of a claim, or of a pre-authorization request if you're confident the services should be covered.
Insurers sometimes stall in urgent cases
Sometimes, insurers stall in approving a claim for a drug that a doctor recommends. They may do this in hopes that patients will just pay out-of-pocket for a medication that could potentially save their lives. Insurers may also impose a requirement that you try less expensive alternatives first, even if they aren't as likely to work.
Working with your provider to try to prove medical necessity can be your best course of action in these situations.
Prescription meds can be cheaper outside of insurance
In some cases, using your insurance for prescription drugs could end up costing you more than if you just paid for the drug out-of-pocket. That's especially true because many health insurance plans provide little coverage for prescriptions until after you've met your deductible, and plans may not cover less expensive generic options.
Shop around for coverage using sites such as GoodRx or ask your pharmacist before using insurance to pay for medication in order to avoid overpaying.
You have the right to request a review or appeal
You have the right to request a manual review of your bills, and to appeal a denial of any insurance claim that your insurer refuses to pay. You can request both an internal appeal and external review, which would mean an independent third party has the final say over whether the insurer will have to pay your claim or not.
Patient advocates aren’t necessarily in your corner
Hospitals and insurers often have patient advocates who are assigned to help those with billing disputes. It's important to remember these advocates work for the insurance company or hospital.
Government advocates and independent nonprofit patient advocates can be a better resource for patients to turn to, as there's no conflict of interest.
Understanding the tricks health insurers try is important for every consumer so you can protect your rights and ensure you get the coverage you need and deserve. By making sure you don't overpay for health care, you can end up saving money that you can use towards other goals, such as paying down debt or saving for the future.