Every health insurance policy should be treated as unique

Every policy should be treated as unique

I would love to say – this company does this every time… but it really depends on the groups benefit for the plan and not the company itself. AND the benefit YEAR the policy is in.

Take for instance – Boeing. We all know it is a huge company, 100,000 plus workers. They have blue cross out of Illinois. Someone with BHP as the prefix (first three letters) in group 00000 may have the ability to go anywhere to get an injection service. Group 7NUXXX has to go to a free-standing clinic – and we have to call the HR to find out why, not the insurance. A facility has enough denials in a specific service with a large group like that, then they will just say no to providing the service, or make a call to tell you that this might not be a covered benefit. And before you get all upset – do you want to get stuck with a bill for $14,000 because you couldn’t be inconvenienced to drive possibly 5 miles or take a phone call to have this weird anomality of your plan explained to you?

UHC AARP med adv does not have a site of service restriction for a colonoscopy, but for UHC Medicaid or commercial, they must go to a free-standing clinic or have an authorization in place for going to a hospital facility setting instead.

Just last night, I had to talk to a couple about the policy they had for years, that covered the cost of a $10,000 surgery just a couple months ago – had only a $300 reimbursement for a very common service. I did the math on potential contracted rates and such, it will pay about 50% with that $300 reimbursement. But the self-pay cost would be $3121. And because this was not one of the big carriers there was some confusion on how I should proceed with the account. I had to call this couple late in the day to explain the issue and potential cost they could incur because of the limits on this specific benefit in their plan.

And another group – the contracted rate for this group is Aetna pricing, and they tell us we need to go to Aetna to authorizations. Exception – a Dexascan is not a benefit of this one large (in our area at least) groups specific plan unless you are over the age of 60. If I try to go to Aetna for the auth, Aetna will say none is required. That is because the very group itself, not Aetna, will personally review the service if the person is under 60 to waive that benefit restriction.

We get reference numbers and such to appeal things like the Dexascan. But once we figure this out, an insurance verifier will know and contact you (or have someone contact you) about the fact we have had plans not pay this service in the past.

The pt gets really upset with us. You need to get upset with your HR, your benefits or the insurance carrier or maybe even the salesman that sold you a policy that you didn’t understand. We are just trying to notify you of an issue that could potentially cost you a lot of money.

Same with Medi-share programs. Yes, they may ask for the contracted PHCS rates, but if the plan, or patients on the plan, have historically not paid, don’t be surprised if a deposit is needed or a facility or clinic treats your medi-share as a self-pay / uninsured type of patient. It isn’t an insurance, they tell you that at every level, don’t get upset when a company opts to not treat it as an insurance.

Conclusion: Get the CPT code, get the diagnosis code, call the insurance carrier and see what the benefit pays, if there are restrictions, if auth is needed.

Authorization requirements can change from month to month or need quarterly review. Molina, UHC and several carriers have a precertification list that is done quarterly. Some plans, like Cigna, the precertification list is reviewed monthly. Most group stuff wont change during the plans benefit year, but they can make annual adjustments when the policy renews for the group.