The Affordable Care Act has brought insurance coverage to millions of people who never had access to insurance before. While more people have coverage, everyone is still at risk of significant financial responsibility for their medical care. Most care is not 100% free to those with insurance. Here are 10 assumptions you need to avoid making in order to limit your risk for medical debt.

1. I have the same insurance I had last year…same company, same policy. I assume that my coverage is the same too.

Policies change every year. This means that you cannot assume that because a service was covered in full last year, it will continue to be covered in full this year. The key areas that experience the most changes are copays, coinsurances, deductibles, covered expenses, doctor networks, and prescription coverage. Take time to review these areas in your policy so that you can be alerted to instances in which you might need to pay for that care.

2. I’m entitled to one free physical/wellness visit each year without any cost to me.

The problem here is in the definition of physical/wellness visit. Every doctor has his/her own definition of the tests and procedures that he/she performs as critical to his/her assessment of a patient’s state of wellness. Each insurance company also has its own definition of what they will cover 100% “free” to the patient. In most instances, the insurance companies base their covered wellness services on the US Preventive Services Task Force guidelines. It is always smart to ask your doctor, in advance of your physical, what codes will be billed for those services, and then speak to your insurance company to see which of those codes are covered by your plan, and what if any, will be your financial responsibility for the exam.

3. My doctor knows what insurance I have and will only bill for services or prescribe medication covered by my plan.

Nothing could be further from the truth. While a doctor might have a sense of whether certain insurers cover specific services, they do not know the details of your plan, and cannot confirm how services will be paid by the insurer until the claim has been submitted and processed. Insurance plans have become too detailed and complicated for any provider to guarantee what is and isn’t covered by your insurance. This is completely the patient’s responsibility to know or to research in advance of care.

4. Escribing saves me time and money.

If you need medication quickly, escribing is the most efficient way to process the request and receive your meds. However, if you have a chronic condition, you know in advance what you are taking and have the time to shop around for the lowest price for your medications. Escribing does not provide the flexibility to do this. Rather than have your doctor immediately prescribe your medication, ask for the name of the medication and dosing requirements. Use that information to comparison shop, both on line, at retail, and through mail order. Once you have found the least costly fulfillment option, you can request that your doctor escribe there.

5. I need surgery. I confirmed that my surgeon and facilitythe are in network. I don’t expect a bill since I have met all my deductibles already.

There are more providers who might provide services related to your surgery, including anesthesiologists, radiologists, and pathologists. These providers may or may not be in your network. To limit your exposure to medical bills, be sure your surgeon knows that you request only in-network care, and if not possible, that you be alerted to the costs of that care in advance.

6. I have no idea how my doctor gets paid but I don’t need to worry because I have insurance.

This is an assumption that could cost you a lot of money. You now need to know what you don’t know…and that means understanding how doctors bill for their services. Review explanations of benefits from your insurance company against bills that you receive from your doctors to ensure that the appropriate services were billed and that your insurance didn’t deny any coverage. When discrepancies arise, you need to question both provider and insurer, or find a qualified medical billing advocate you can help.

7. I’m thrilled I was able to buy a Blue Cross policy on the Exchange because Blue Cross is the only plan my doctor takes.

Exchange plans are completely different products from off-exchange plans. Often the plans only cover participating providers in the state in which the policy was purchased. Additionally, these plans typically offer no out-of-network coverage. The networks for the Exchange plans are often very narrow and limited, because many doctors don’t choose to participate, even when they participate with the same insurer off of the Exchange. Be sure to ask your doctor in advance if they participate with the Exchange plans, or you could be saddled with a hefty bill.

8. My plan doesn’t require that I select a Primary Care Physician so I won’t.

It would be a good idea to call your insurance company and ask about this. Some plans truly don’t require a selection. However other plans, while they don’t require the selection, treat any doctor not listed as your PCP as a specialist. This requires that you pay a specialist copay which is higher than the PCP copay.

9. My doctor’s practice was recently purchased by a hospital. He’s still in the same office, with the same staff. I was told nothing changes on my end.

This is certainly a trend that continues in medicine, but you must be careful. One of the reasons that doctors make this move is because the fees that insurance companies pay to hospitals are higher than what doctors are paid independently. This means that if you have a deductible, an EKG that might have cost you $32 when it was done in the doctor’s office when he was independent could cost you hundreds of dollars now that he is a hospital employee. Additionally, hospitals can charge facility fees for some services, on top of the provider’s fee. This, again, could become your expense particularly if you haven’t met your deductible.

10. I just received a bill from my doctor, a lab, and the hospital, for my recent trip to the ER. I guess I need to find a way to pay for these.

Just because you received a bill doesn’t mean it is correct. It could reflect charges for services never provided. It could have been improperly processed by your insurance company. In any case, it should be reviewed closely and questioned. And then before you pay, negotiate….or find a medical billing advocate to provide assistance and negotiate for you.


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