Drs. Oz & Roizen: Make Sense of Your Health Insurance

The only thing worse than being injured or falling ill is not having faith your insurance provider will help get you back on your feet. Follow this month’s tips for peace of mind.

Q: I’ve got a new plan and need to choose my doctor from those listed in the network. How can I find a good one?

A: Choosing a new doctor can be overwhelming—after all, it’s one of the most important health decisions you can make. But take heart—the right match for you is out there. Here’s how to narrow the field:

Ask around: This is probably the simplest, most effective way to find a good doctor quickly. If you know someone who has health issues similar to yours, start there. Otherwise, check with your friends, relatives and co-workers and compare their recommendations to your list of in-network providers. You’re bound to discover at least a couple matches. Another great resource: local emergency room nurses. They know which docs are the most dependable, responsive and caring.

Do a background check: Once you’ve narrowed the list to a few possibilities, check the physicians’ credentials with the American Board of Medical Specialties to be sure their certifications are legitimate. You’ll want to verify that your candidates attended an accredited medical school and have been board-certified for at least three years. Then check the doctors’ own websites (or call their office) to find out their hours, whether they take emergency calls and if they’ll answer personal or general questions via email. And don’t forget to ask which hospitals they use—if one of those facilities is not also part of your network, keep looking.

Make an appointment for a meet-and-greet: Even if you’re not due for a checkup, it’s smart to schedule a consultation. By the end of the meeting you’ll have a good sense of whether you’re compatible. Did you feel relaxed, or rushed? Anxious, or at ease? Did you receive clear, understandable answers to your questions? You deserve a doctor who gives you the time and attention you need to become your healthiest self—so don’t give up till you find one!

Q: What is the difference between Point of Service (POS) organizations and Preferred Provider Organizations (PPO)?

A: The biggest difference between the two types of plans is flexibility. Let’s start with Preferred Provider Organizations. PPOs offer a list of in-network doctors and hospitals; the company has negotiated discounted rates with these docs, and you typically are charged a co-pay for visits or care. Members don’t have to designate a primary care physician, and they can usually see any specialist without a referral. PPO plans do give members some coverage for out-of-network providers, but you may have to pay for the treatment up front—sometimes a considerable amount—and submit your receipt for partial reimbursement later. Many plans also have yearly deductibles.

Point of Service plans, on the other hand, often don’t require members to meet a deductible for in-network care, but they provide very little, if any, coverage for out-of-network doctors. You’re required to designate an in-network physician as your primary healthcare provider, and you’ll get most of your care from a designated network. The only time out-of-network doctors are covered is when your primary doc refers you to one.

Q: My employer will allow me to set up a health savings account. Should I?

A: If you have an insurance plan with a high deductible (one requiring at least $1,200 for self-coverage and $2,400 for family), a health savings account (HSA) is a great way to set aside pre-tax money for medical expenses, including those not covered by your insurance. You’re allowed to stockpile up to $3,100 a year if you’re single, or $6,250 for a family pre-tax, like a 401(k).Here’s what you need to know:

• To be eligible, you can’t be covered by any other health plan besides yours, nor can you be a dependent on someone else’s tax return.

• When you make a withdrawal from your HSA to pay a medical bill, like a doctor visit, prescription or lab test, you can withdraw that money tax-free.

• Unlike flexible spending accounts, whatever is left at the end of the year rolls over for you to use in the next.

• You can use the money only for medical expenses. If you make withdrawals for any other reason before age 65, you’ll be subject to a 20 percent tax penalty on top of your ordinary income tax. (After 65, withdrawals for nonmedical expenses are taxed at your regular rate.)

• If you switch employers (or private plans) midyear, you can roll over your funds, just like a 401(k). If your new employer doesn’t offer an HSA or you change to a lower deductible plan, you keep the money for out-of-pocket medical expenses but can no longer contribute.

Q: When I can’t budge the insurance company on a disputed reimbursement, are there any government agencies that might be able to help me?

A: Yes. But first, be sure to do everything you can with your insurance company to clear up the issue internally. After you’ve reviewed your health plan’s policies thoroughly, contact the customer service office to plead your case. If they still won’t budge and you’re sure your reimbursement has been wrongfully denied, it’s time to begin the formal appeal process. Your insurance policy will outline the paperwork required, which usually includes copies of your medical bills and a letter from your physician describing why your treatment was or will be necessary.

 Many health plans have several steps in the appeal process. If your initial appeal is denied, you most likely will have additional appeals available. Only after you’ve exhausted the internal appeals process should you turn to your state insurance commissioner’s office to request an independent review. Navigating the appeals process can be difficult and stressful, so if you need more information and guidance, visit the Patient Advocate Foundation (PatientAdvocate.org).


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