Recent headlines say it all. More consumers are facing huge medical bills
and shock due to confusion over health insurance coverage.
TIME magazine, March 3, 2016, TIME Magazine, March 3, 2016,
"The Hidden Cost of 'Surprise' Medical Bills"
Wall Street Journal, March 7, 2016,
"$lammed by ObamaCare"
According to Key-Whitman Eye Center’s
President and Chief Surgeon Jeffrey Whitman, M.D., “What people need to understand is they can’t call their
doctor’s office and say, ‘I’m on ABC insurance, am I
covered?’ and expect a definitive answer on the spot. The rules
are constantly changing, and both patients and physicians need to be patient
with one another and take steps to ensure the patient is covered.”
Dan Chambers, Executive Director at Key-Whitman, agrees. “The ‘pains’
consumers are feeling now reflect the stage we’re going through
in the structural transformation of our healthcare system under the Affordable
Care Act. While many challenges arose last year, additional changes went
into effect January 1, 2016, that will have an impact on patients this
year,” Chambers says.
So what should YOU do to help ensure you have health insurance coverage?
Follow these 7 steps:
1. Be aware that you will need to advocate for yourself.
“When you think of the term ‘patient advocate,’ most
people automatically think of the insurance company or doctor playing
that role. However, in today’s insurance environment, things have
changed. Now the patient needs to advocate for himself or herself. What
we find now is what the patient says and asks for usually matters more
than anything else,” Dr. Whitman says.
2. Tap into resources at your insurance company for help.
While you DO need to be your own best advocate, you don’t need to
go it alone. Most insurance companies have people on staff to help you
figure out your insurance coverage and what physicians and specialists
you can see.
These insurance resources are typically called a patient advocate, patient
navigator or customer advocate. You can reach out to these contacts should
you have a problem finding a doctor who is in-network or need to request
approval to see an out-of-network physician.
3. Scrutinize your current insurance card and read your insurance policy
Most people receive a new health insurance card in January. Before you
toss your old card, compare it to the new one to see if anything has changed.
For example, has your coverage changed from a PPO to an HMO? Are referrals
required to see a specialist? Have co-pays increased?
Dr. Whitman shares common changes consumers might find on their health
Once you review your insurance card, move onto your insurance policy. Compare
last year’s plan to your new plan. A few things to look for include
- Co-pays for doctor visits, emergency services, etc.
- Preventive services covered.
- Prescription drugs covered and co-pays.
- Maximum out-of-pocket expenses.
- Referral requirements.
- Doctors and specialists included in the insurer’s network.
- Coverage for using healthcare providers in AND out of network.
These are just a few areas to review. An insurance company representative
can explain your new plan and what changes in coverage to expect.
Don’t assume your insurance coverage hasn’t changed.
The reality is, even if you didn’t request a change to your insurance
policy, your coverage may be different. As insurance companies navigate
the new landscape evolving under the ACA – or ObamaCare –
many need to make adjustments to their plans and provider lists.
5. Make sure to choose a primary care physician (PCP) who meets your needs.
If you don’t choose a PCP (i.e., a family practitioner or internist),
your insurance company will choose one for you. Many insurance plans have
a restricted network of providers you can see, and not all PCPs can refer
you to the specialists you trust.
Dr. Whitman explains why it’s important to choose a primary care
physician and that when patients advocate for themselves, insurance companies
are more likely to make exceptions for specialists.
6. Know that you may need to see your PCP
in person, before he or she can give you a referral to see a specialist.
According to Key-Whitman Director of Patient Accounting Matt Chapman, “If
you’ve had a long-standing appointment with your specialist (i.e.,
glaucoma specialist, immunologist, cardiologist, diabetes specialist, etc.), and your insurance
policy changed in the meantime, contact your insurer BEFORE you head to
the specialist’s office. (Keep in mind, the insurer’s list
of in-network providers can change at anytime.)”
You may need a referral from your PCP first, AND that specialist may no
longer be in the insurance provider’s network. If you’re a
Key-Whitman patient, our insurance navigators will ask you a series of
questions to determine what services your insurance covers here.
7. Consider opting for healthcare providers that cover a large geographic area.
“When picking a specialist, it’s usually important to find
one that has a large geographic presence. For example,
Key-Whitman has locations all over the metroplex. We have ophthalmologists, eye surgeons and optometrists
in Arlington, Dallas, N. Dallas, Mesquite, Plano and Richardson.
That avails us to getting into more insurance plans, which means you’ll
have an easier time navigating those insurance waters and getting to our
most convenient office for the best eye care possible,” says Dr. Whitman.
Healthcare providers can help patients by taking a proactive approach
During this tumultuous time, it’s important for healthcare providers
to be proactive and work with patients to find a solution. As Dr. Whitman
explains, “We’re here to educate patients about the process
and explain that the patient is the best person to advocate for themselves.”
You’re also better off choosing a healthcare provider who works hard
to be included in as many insurance networks as possible.
According to Dr. Whitman, “We want to be there for our patients when
they need us. For example, we
worked closely with Veterans Affairs (VA), so we could help more vets get quality eye care and
cut down wait times. At Key-Whitman we make sure we become approved by as many health insurance
providers as possible, so we can be available for all of our patient’s
eye care needs.”
If you’d like to find out what Key-Whitman Eye Center vision services
your insurance covers, call (855) 410-8106 to speak with an insurance
navigator. When you’re ready to schedule a visit with one of our
eye care professionals, you can fill out our handy online appointment form here.
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