There’s a FB group called Harnessing Healthcare that has lots of good info. I think someone said they’d compile links in the docs section. And if you can’t find what you’re looking for it might be a good place to ask for that kind of resource.
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Might be helpful to have some folks at the target level read it. I am also a novice at navigating healthcare and insurance. But getting to the point where I need to understand it better.
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Yay! Good luck. It’s a big thicket to navigate but you’ll get there!
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Are you interested in navigating the Healthcare Marketplace (ACA plans) or do you have a plan through your husband’s job you want to understand?
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The latter!
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Would be! It’s a graphic novel through a traditional publisher so I have a limit on what I can do, but I’ll keep that in mind when we get to final drafts.
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Do you understand the terminology like deductible, co-pay, co-insurance and what the letters like HMO or PPO or PCP stand for?
ETA: Are you trying to understand how best to use a plan you already have or to shop between plans for enrollment?
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Somewhat, and looking up terms with basic definitions is easy enough for me. It’s more the way things functionally work that I’m stuck on. I am confused about what goes towards my deductible, how it works to have two types of deductibles, etc. My husband recently changed our plan and now we are navigating that. I’m trying to figure out to what extent I have to do things too, like when I pay OOP for things, how what we pay for appointments is different now that we have a deductible (like the price of my meds all went up, and I want to know if his therapy will now go up) etc.
The very strange thing is that when I log into my account it says nothing has gone towards my deductible. And I spend quite a lot on healthcare so I don’t understand how that is possible. And if copays and medication don’t count towards it, like, what counts?
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Does your plan have preferred providers? They are in-network. For a lot of plans, anyone who is not in network (out of network) is not covered and those funds don’t apply to the deductible. Could that be the reason?
Some things are not covered under some plans. For example I just bought new insurance that does not cover acupuncture.
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The other thing to find out is if pre-approval is required. That’s when the insurance company wants to say, “Yes, you can do this and we’ll pay for it,” before you have something done. That’s another reason why they will deny claims, even if it is supposed to be covered.
My plan does and that’s what I thought! I asked and she said if they “take my insurance” they are in network and they are only out of network if they tell me I have to submit something for a refund. So according to that everything I do is in network? But I also have an in network and an out of network deductible. And both say I have spent $0 towards it so even if some are out of network that doesn’t make sense to me.
ETA: Yes, the preapproval is something I understand!
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Based on my experiences, I’d call the insurance company and ask what happened.
The doctors are supposed to file the pre-approval paperwork and it doesn’t always happen. I often confirm that it has happened beforehand because I’ve had several bad experiences. I’ve also managed to get a post-approval for a couple of things.
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Have you found on the web the EOBs for various claims? That’s the paperwork that lays out what was billed, how much was covered, how much you can be billed.
ETA: EOB stands for Explanation of Benefits
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So you think possibly they did not pre-approve anything I’ve had done, which is why it did not count? This is very helpful btw, thank you.
It’s possible. If they say it was pre-approved, get the pre-approval number. The provider can re-submit the bill - though they have little motivation to do so if you’ve already paid.
I’m glad it’s helpful. Insurance is very confusing and I wish none of us had to deal with it.
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Sorry, one more question. If it was not pre-approved…wouldn’t I be paying the full cost? Because, for example, I can look at past claims for things like lab work, etc. and all that was fully paid by insurance! Doesn’t that mean it’s approved? Or no?
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Co pay for appointments and drugs do NOT count toward my deductible. What does is everything else- all my D&C surgery costs were partially covered, I paid the rest, that all counts. The follow up appointment that was copay did not. Does that help? If you haven’t had any scans, labs, or procedures, only appointments on co pay and drug costs, there might NOT be anything applied yet.
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It’s also possible for a healthcare facility to be in-network but for the specific provider who works at the in network place to be out of network. Watch out for that one.
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I would start with the EOB and see what it says about why it was denied. Then find out if a pre-approval was required, and if one was filed. Sometimes the doctor’s office does not file the paperwork. If they didn’t file it, you can ask if it can still be filed. I had that situation one time where the doc did not file the paperwork; it was a pain to get her to do it but she finally did, and the insurance company issued a post-authorization. I was able to give that number to the provider who did the service. I assumed they got paid but at least they stopped calling me.
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