In surveys across the country this past month, people were asked if they were satisfied with their health insurance? A majority answered, "yes." Then they were asked if they had ever had made a claim on their insurance? Many of those people admitted that they had not, or had only made minor claims.
How many of us know for certain that our health insurance policies will pay for our medical bills? Do we fully understand the terms of our policies? How many exclusions and exceptions truly exist, and how do we identify them before we are rendered seriously ill or injured?
In effort to answer these questions, I took the time this morning to call my health insurance company, and have an agent walk me through the process of making an insurance claim. I cannot recommend enough that all health insurance policy holders take the time to do this with their insurance company. People pay for insurance policies to avoid debt. We hedge are bets, pay our premiums, and hope that we never need to make a claim. In turn health insurance companies hope that you stay healthy, and they can collect on your premiums for many happy, healthy years.
I should first explain that I intend to use my health insurance only in the event of a catastrophic injury or illness. My rates were raised 21% this year, and the reason given by my insurance company was that I used my insurance. I cannot afford another increase in my rates, therefore I will no longer use it for normal medical claims. I do not particularly like this scenario, but I made this choice to spare my family the burden of dealing with any major debt incurred by my medical bills.
If my intent is to the use this insurance only in the event of an emergency injury or illness, I must assume that I may not be conscious when I am admitted to a hospital emergency facility. My partner or closest relative may have to deal with the insurance companies, and I want to make certain that the process goes as smoothly as possible. In short, I made a phone call to find out what my premiums pay for, and how much it will pay to treat me in the event of an actual medical emergency.
I called the insurance department and asked to be put through to someone who would be able to review my policy and walk me through the process of making a claim. Getting to this person took about five minutes and several switches.
Eventually I was connected to the proper person, a claims associate. I explained to her why I wanted to walk through a claim. I wanted to write up a set of instructions, to give to my designated caregiver in the event of an emergency, that would allow them to make an insurance claim on my behalf should I be unable to so myself.
These were a few basic facts I wanted to verify up front:
1. To verify the amount of my deductible, and my maximum out of pocket expenses (in my case 50/50 of the first $5,000).
2. To verify that my policy authorized me to pick any medical provider.
3. To make sure that my HSA account included enough funds to pay those expenses.
The associate verified all the information. Doing provided me with a baseline figure from which to calculate possible medical expense, which could then be covered by money from my Health Savings account. We proceeded to initiate our test claim. The scenario was simple, and very possible:
I have a stroke, am rendered unresponsive, and am taken to Providence hospital. Per instructions, a designated person meets me at the hospital, gets my insurance card and the instructions that are kept with it.
These are the steps they will have to follow, and the expenses they may have to arrange to pay.
They call ahead to authorize my visit to the emergency room. If I go to Providence, the hospital is listed as a preferred provider. The visit to the hospital is fully covered after I pay the deductible and out of pocket expenses. If, for some reason, I am sent to Alaska Regional, that hospital is not an authorized an hospital provider. This means that my insurance will only pay a set amount for the visit, attending physician's fees and any lab work or test procedures.
Great, I am admitted to Providence. I should have no worries, and my family will only have write a check out of my HSA for the amount of the deductible and the out of pocket expenses. I can plan ahead for that, and feel good, right? I will have done all that I can to protect my family from medical debt, right?
No. Providence Hospital emergency is covered under the PPO plan, but the individual doctors who are called upon to treat me may not be, nor may be the labs and test facilities that service the hospital. In order to avoid incurring additional medical expenses, I will need to have my caregiver provide specific instructions to the emergency room that I am only to be administered treatment that is authorized by my insurance company by doctors who are preferred providers. If not, any charges that the insurance company deems not "reasonable and customary" will be billed to me by the physicians and facilities that treated me.
After establishing the limitations of my policy, I had the following discussion with my claims associate. I would like to take a brief moment to compliment this woman on the sincerity with which she answered my questions. I think she learned a lot from our conversation today as well, and I hope she was being taped for quality purposes. I asked from very tough questions. She was superb,and did her best to be helpful. This discussion has been written to the best of my recollection, and does not contain direct quotes.
Jeanette - My ultimate goal in paying for this insurance policy is to spare my family unreasonable medical debt, yet it appears that I may not be able to do so under ordinary circumstances.
Associate - It does not appear so. We can't guarantee that all services will be covered. We will only pay for reasonable and customary medical expenses. We cannot determine ahead of time what may or may not be covered. That would have to be done at the time of the claim.
Jeanette - So to summarize: the only way I can insure full coverage of medical expenses is to make sure that I am only treated by doctors who take part in the Preferred Provider program, and make certain that any labs, equipment and test procedures are pre-approved prior to service?
Associate - Yes.
Jeanette - What benefit do I receive by paying for a policy that allows me to choose my own medical provider, if my policy does not cover all expenses?
Associate - It would allow you to choose your own doctor, and treatment plan, thereby giving you more options.
Jeanette - Why would I chose options for which I cannot pay? It seems that in order to be able to choose who and how I am treated, I must be willing to risk plunging my family into deep debt from unanticipated medical expenses.
Associate - That would seem to be the case.
Jeanette - If a hospital emergency room is considered preferred facilities, but the doctors and treatments found within them may not be, it appears that the only real way to avoid incurring unanticipated medical debt is for me to have a living will drawn up that would clearly specify to my designated caregiver and to hospital personnel that I request to be treated only to the extent that I am fully covered by my insurance. This is similar to having a living will that would specify my desire not to be resuscitated (DNR)in the event that I am declared brain dead.
Big pause...
Associate - That might be the only option.
Jeanette - I don't mean to sound brutal. I really don't. It's just that I once spent nearly eight years paying off a hospital debt incurred when I wasn't insured. I had hoped that by having insurance, that wouldn't happen again. Now I learn that even with insurance, I will have to take further measures to avoid repeating that experience. I am a healthy forty-two year old, and I need to protect my family. I have to do what is necessary to give them a chance at a good life.
Associate - It sounds as if you are really taking the time to plan ahead.
We talked some more. I told her about my father, and how he took the time to write up a living will before he died. He loved us and wanted to protect his family. She was very nice. I hung up and sat down to take a long, hard look at my situation.
So here I am, hypothetically unconscious in a hospital. My family has gathered around me worried sick that I will not make it. Because I love my family, and wish to avoid leaving them a large medical debt, or for that matter, myself should I hopefully recover, I have drawn up a living will. I have chosen a designated care giver who must make some very hard decisions on my behalf. That person will give a copy of my living will to the doctor at the hospital. That doctor will have to honor my wishes, and treat me only to such an extent that my bills will be paid in full regardless of the outcome of my visit. If I die waiting for approval, he must stand by and accept it.
I realize my situation may be a bit stark, but think about it this way. Most of us do not wish to be in debt. We were taught that you do not purchase what you cannot pay for in a reasonable amount of time. We were taught that a person takes responsibility for ones own debts. We take out life insurance so that what debts we have can be paid without leaving our families financially compromised. Why then, would I willfully place my family in financial jeopardy by accepting treatment that I cannot afford to pay?
Health care and its relation to health insurance is a very complicated subject, but we can do our part to better understand how it works in our own lives. How else will be able to distinguish what is false from what is true? Adequate health care should not be presented to Americans in black and white terms: you either accept a mountain of debt and get the top notch treatment you deserve, or keep your family and yourself out of debt by accepting whatever treatment for which the health care insurance companies are willing to pay. We must seek solid ground, and insist that whatever solution we choose be affordable to all.
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