Preventive Care and Insurance

This week I want to talk a little bit about preventive care and insurance. Let’s begin with a client example. I’ve recently had a client – a young, healthy adult female – call me after she had her annual checkup. The doctor convinced her to have many extra tests done, and had said, “Your insurance is preventive, it will cover it.” Well, it turns out insurance didn’t cover it. Being a younger client, she did not have much experience with insurance and took the doctor’s word for it.  Bear in mind that these were also tested that the client had had no previous history or concerns with, and was unnecessary. She now has a bill for over $600 from the physician’s office.

I am working with her and the physician’s office on getting this resolved because firstly, the doctor should not be telling patients what is or is not covered on their insurance plans, because they actually do not know. A better way to handle this would be for the doctor to check with the insurance billing staff in his office before running the test, and that way he would have known that it wasn’t covered.

The factor that really concerns me regarding this case is the up-selling. I am referring to the notion of performing tests or procedures that are unnecessary. This is not right for numerous reasons – including the fact that the patient will now receive a bill. As a patient, it is vital that you know what is covered, and what is not covered on your plan.

Remember, having a doctor tell you that ‘your insurance will pay for it’ can be a red flag – just because your insurance may pay for it, doesn’t mean it’s necessary. Did you know that the attitude that ‘insurance is going to pay for it, and it will not cost to me’, is actually untrue? This is because the more claims that you file, whether it’s preventive or for illnesses, the higher the premiums are going to end up being on your end. So in the long run, it is not free. All those preventive items get figured into your premium. Many people do not realize this, and part of my role is to help educate you on how your insurance coverage and premiums are calculated.

A good rule of thumb to use, is in the doctor’s office say, “Can we do this next time once I have determined exactly what is and is not covered?” This ensures you do not end up with a large bill, or that you realize what the cost will be for a necessary test, and agree to pay it, knowing insurance will not cover it. This also allows time to determine if the procedure is completely necessary – and be sure to ask the doctor exactly why the tests are being recommended.

I want people to get the treatment that they need. If screenings and preventative tests are warranted, then that is great and needed. But if there is absolutely no history or risk factor to the condition, it may not be necessary. We just all need to do our due diligence. If something just doesn’t feel right, you can refuse tests. I’m not saying the doctors don’t know, but unfortunately, there are some practitioners out there that are just going to run everything under the sun because they feel like they can collect that money from insurance. Thankfully they are few and far between, but it does happen. So, it’s up to you as a patient.

So really the takeaway from this article is just because something may be covered by your insurance, doesn’t always mean it’s a necessary procedure. We all have to do our part to help keep healthcare costs down and to help keep premiums down.

I want to help you by making you aware that doctor’s office’s should not be relaying insurance coverage information to a patient if they actually have not verified benefits. And even then when you verify benefits, there’s no guarantee of payment, no matter what insurance company you have, when you call to verify benefits, the disclaimer says this is no indication of payment. They will not guarantee any kind of payment until they receive an actual claim, because they need to look at diagnoses. If the doctor is doing some basic routine tests, a lot of those are covered, but there are limitations even on those because sometimes they’ll only pay for certain tests once every, so many years.

Please feel free to reach out to me for any questions you may have, or book an appointment on my website, www.jkappconsulting.com.

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