Saving Money on Your Health Care:  Getting Your Insurance Plan to Pay

By Peggy Owens

“To be or not to be, that is the question.”  Shakespeare was not talking about health care or health insurance reform.  But he might have been.  As I am writing this in early fall, we have no idea where the government is headed.  The topic has understandably dominated the news media for months.  There was a lot to cover.

But as someone with a chronic illness who spends what seems like 20 percent of my waking hours on health care (office visits, laboratory tests, and telephoning billing offices and my own health insurance customer service), it occurred to me that there are things we can do on an individual basis to minimize our health care costs.  Regardless of the final outcome of our national quandary, we are our own best advocates.

Choosing a health care plan is a big decision for you and your family and it is important to educate yourself on the options available to you.  If your health insurance is provided by an employer or union (or a former employer, if you are retired), you are lucky.  If the employer contributes to your premium cost, even better.  But even if the employer does not, you are probably benefiting from being in a group where costs are spread over the members of the group so that the insurance company is able to reduce the premium costs to all of the members.  This is the basic meaning of insurance, after all.

On the other hand, if your employer does not assist in the payment of the premium, a better option may be to shop for an individual or nongroup plan. There may be fewer benefits and there may be higher out-of-pocket costs (like deductibles, coinsurance and co-pays), but if you are ready to take on that part of the risk yourself, it may be possible to save money in monthly premiums and have insurance only for more catastrophic events like hospital stays and serious or long-term illnesses.   Your decision will be based on the financial situation of your family and your willingness to assume a larger part of the risk.

Other things to consider when choosing a plan

What exactly is covered?  For example, if I or one of my dependents is of child-bearing age, is pregnancy covered?  Are one of us likely to need treatment for mental illness or substance abuse and is that covered?  Are so-called wellness visits covered?  Can I have a physical periodically at the expense of the plan or must I pay for that?  If my family likes to travel, what is covered when I am away from home?  Note that some benefits are mandated by state law, but often at only a minimum level. So that it is important to know how extensive the coverage is.

Maybe an even better question is what is not covered?  Dr. Will Nicholson is a doctor who decided to move from a group plan to a nongroup plan in order to understand what his patients were complaining about.  Recently on CNN he advised, “Know what the holes are in your coverage.”  This may be difficult to figure out. And then, how much freedom or restriction can you live with?  In every plan that I know about, even the most expensive and least restrictive ones, you will always fare better if you use a provider who participates with your plan.  Do your favorite providers participate with the plan you are considering?  It is best to check with the providers as they can cancel their participation when their contract comes due without you knowing this.

Now that you have made your decision about what plan is best for you and your family, what else can you do to minimize your costs?

  • Know and follow the rules for your type of plan.  For example, in a “gatekeeper” plan (such as an HMO), you must select a primary care physician and it is her responsibility to refer you to specialists who are also in the network.  However, it does not hurt for you to ask when you call the specialist’s office to make your first appointment if he or she participates in your plan.
  • If you are in a plan that requires written referrals, keep a copy.  If you don’t have access to a copier, ask for a copy at the specialist’s office as you turn it in to them.  I can’t tell you how many times my plan calculated a claim at a higher out-of-pocket cost to me than it should have been because they swore that they had not received a referral form with the claim from the doctor.  It saved a lot of time and aggravation for me to be able to fax it to them, using my copy.  Be sure to get a name and direct fax number from the customer service representative with whom you have been speaking with at the plan.
  • Don’t automatically pay a bill from a provider because you have received one.  My sister-in-law, who was in failing health, received a bill for $2,300 from a physician and promptly sat down and wrote a check to cover it because she did not want to be in debt or risk ruining her credit rating.  The bill had been mailed out by the physician’s computerized system before the insurance company had an opportunity to respond to the claim.  If you (or your elderly parents) receive a bill, be sure that you understand why there is a balance due.  It should be equal to the out-of-pocket costs you are expecting, based on the plan you are in:  deductible, coinsurance or co-pay plus any balance for which you are responsible if the provider does not participate in your plan. Most providers are honest and will return or credit your account with any overpayments occurring once your plan has paid on the claim, but it may require a lot of followup from you and why should they have your money in the meantime?
  • On the other hand, don’t ignore bills from a provider indefinitely.  If enough time has passed since you saw the provider that the insurance company should have paid the claim (say, six to eight weeks) and you are receiving a second or third bill from the provider, begin following up.  Start with the insurance plan to find out why they aren’t paying and take it from there.  Maybe you owe it or maybe you don’t.  But again, be sure you understand the charges and whether or not they are not covered.
  • Look at any Explanation of Benefits (EOBs) you receive from your health plan.  Sometimes you can detect something that is going to need your attention before you receive a bill from the provider.  The EOB will likely indicate the provider’s charge, the amount the plan allows for the specific service you received, the amount of your deductible still outstanding (once you have paid for services equal to your deductible in a given plan year, this should be zero), the amount the plan actually paid to the provider and the amount which you owe.  If you receive a bill from a physician and you did not receive an EOB, call your plan’s customer service department and ask for an explanation of their payment. If their calculation of the balance you owe is different from the bill received from the physician, call the physician billing office.  More physicians are relying on outside services to do their billing and, frankly, I find this is a plus.  Unlike the tired medical office clerk or receptionist who has too many responsibilities and can’t quite grasp what you are talking about, the outside billing services deal all day with billing problems and insurance plans.  They are more likely to understand your questions and be able to explain what you owe and why.  Have your EOB handy when you call.  Last week I had an otherwise knowledgeable billing specialist tell me that the doctor’s office overcharged on my husband’s co-pay because the insurance plan “determined the amount of the co-pay.”  I was able to point out to her that I had the EOB right in front of me and the co-pay was supposed to be less.  (Not to mention that it is written right on his membership card!)  She had to leave the phone for a few minutes to check her files, but came back apologizing because I had been right. I generally save EOBs for a year, longer if something on them has been appealed and is still pending.
  • Another reason for checking your EOB?  You can check for fraud.  My health plan has a special hotline for fraud.  I used it once even though I felt the provider may have made an honest mistake.  I called the provider’s billing representative who agreed to check on the information I was giving her and return the mistakenly received money to the insurance plan.  But calling the fraud hotline was one way of assuring that if the refund was not received, it could be deducted by the insurance plan from its next payment to that provider.

Be firm but be nice.  Remember that old adage, you can catch more flies with honey than with vinegar.  I know it is a frustrating system to deal with and that is not likely to change no matter what reforms may be adopted.  But the clerks you will be talking to are likely overworked, underpaid, tired and may actually have less knowledge than you do.  Expect that they will need time to unravel what you have brought to their attention and be patient. In this way, you may not only be saving on your own costs for health care but hopefully all of us together can have an impact on the system as a whole.

Peggy Owens retired as a health benefits administrator with the state of Maryland.  While there have been changes in health insurance since her retirement, most of the information in this article she learned from personal experience.  She may be reached at [email protected]



2.   OUT-OF-POCKET COSTS (deductibles, coinsurance, co-pays)






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