Imagine your horror when you discover your emergency surgery is not covered by your health insurance

Imagine your horror when you discover your emergency surgery is not covered by your health insurance. You have no idea what to do. AND you’re a recovering patient!

The moral is that if you, or your company for you, purchased a health insurance policy more than five years ago, it would be prudent to review your benefits. You might find quite a few very unpleasant surprises. Wouldn’t it be better to know now rather than later, when you need your benefits and it’s too late to make changes.

The costs for medical services have soared. Many of the benefit amounts in health insurance policies do not cover the current charges.

I recently learned of a case where the patient bought his policy many years ago when medical costs were far less than they are now. His policy stated that his coverage for anesthesia services was one-third of the surgeon’s fee. Meanwhile, the cost of anesthesia services has greatly increased.

The maximum or “cap” in his policy was $1,000, leaving him with a significant - unexpected - out-of-pocket amount for the anesthesia service.

This same patient also found that his deductible was not an annual charge. He learned that he would have to pay the sizeable deductible for each medical event and/or procedure. Unfortunately, he found this fact right before his surgery, too late to make any changes in the policy.

He also found that lab charges would not be covered at all. His policy states that the cost of lab work would not be paid if it is billed from a site outside the hospital; only lab charges billed from the hospital itself were covered. Nowadays, many hospitals outsource some of their services and patients are stuck with more out-of-pocket charges.

Had this patient carefully read through his policy – and done so annually to remind himself – perhaps he could have made changes in his plan to better protect himself.

If your policy is through your company, they likely have an annual Open Enrollment period during which you can make changes to your health insurance plan. Use this annual event as the time for reviewing your policy.

Another reminder: check the pre-authorization, or pre-certification, requirements in your policy. This means calling the insurance company, describing what’s going to happen, and receiving approval for the procedure prior to the actual procedure. Often the physician’s office will handle this step. Make sure that it occurs.

Keep good records of your conversations. Note the date, the time, to whom you spoke, and what was said. Until you know for certain, assume any medical treatment requires pre-certification (often called “pre-cert”).

I hope this information has encouraged you to review your health insurance policy at least annually. You surely don’t want the financial surprises this patient found.

After fighting her own health insurance company, Leland Draper founded The Draper Forum to assist clients as an advocate for Georgia citizens regarding medical insurance. She deals with claims departments and agencies, overseeing claims, including Medicare, Explanations of Benefits, and supplemental policies. On behalf of the client, she copes with physicians’ offices, service agencies, hospitals as well as auxiliary labs and services. She provides this service for her clients because managing, on your own, the chaotic muddle of bills and insurance paperwork is emotionally exhausting and can affect recovery. Ms. Draper can be reached at http://www.thedraperforum.com and at mld99@juno.com.