As many massage therapists also have to take care of their own health insurance and that of their families, I feel compelled to pass on what I have learned, so that what happened to me does not happen to you too.
Prior to my husband Francis’s surgeries to fix a torn meniscus and repair a bilateral hernia that happened as a result of an accident, I called my insurance company to find out what they would cover. I was told they would cover 100% of what was usual and customary (U&C).
I questioned them pretty extensively about how they came up with these U&C amounts, but they assured me that we had nothing to worry about. They also told me that we had a great policy because we were not limited to any network and Francis could go to any doctors he wanted.
So I felt pretty confident that after our $2500 deductible our bills would be paid and so Francis went ahead with the surgeries.
A few weeks later the bills stared pouring in. Here is what happened.
1. Even although the surgeries were the result of one accident we were charged three deductibles totaling $7500 (one for his knee and one for his hip and one for the hernia (even although the hip pain was the result of the inguinal hernia). Our deductible is per occurrence and not annually and it is up to us to prove to them that the injuries are related to the same accident (even although all the doctor’s notes support this!)
2. The U&C rates that they actually paid out were in most cases 1/3 or less of each bill (after our deductible of course).
3. Even although they told us before hand that he could have all the surgeries done at the same time (which cost them only one hospital bill and not three) after the fact they said it was not usual and customary to have them done on the same day and disallowed most of the charges.
4. Because our policy is not part of any network we have ZERO protection and the doctors and hospital offer ZERO discount on the bills so we are responsible for 100% of what the insurance doesn’t pay. Which is about $20,000.
So here is what I have learned:
1. When you are part of a network, even although you are limited to which doctors you can see (often ones employed by the health insurance company) at least you have some protection from escalating bills.
2. Watch these U&C rates! Unfortunately the amounts that your insurance company actually pays out for each service is developed by a proprietary formula unique to each company and they are NOT required to disclose how they come up with the formula.
So you may think you have a great policy because it pays out at 100%. But in fact a policy that pays out at 80% may actually have more realistic U&C rates and therefore be a better policy.
3. Watch these “per occurrence” deductibles. You are better of with a clear cut annual deductible.
4. Keep great notes of every conversation you have with your insurance company. (In fact I started recording mine – with permission of course) including who you spoke to, when, and what they said. This will become invaluable if you run into problems.
I do intent on fighting this and will keep you posted. Meanwhile does anyone have a great health insurance policy out there? I’m looking for a new one!