Understanding Your Health Benefits

I have a background in HR and understand what some of the insurance jargon means, but I was really put to the test this past year {2007}.

I learned our family's health benefits inside out since we had major surgery and hospital procedures that were processed. I was getting EOB's (explanation of benefit) and bills left and right from our insurance and medical providers. Some of our bills were saying our insurance hadn't paid. I would call our insurance provider and the doctor left something off. Dealing with this is very frustrating and overwhelming, especially if you have a catastrophy going on at the same time!

I want to encourage you to truly learn your benefits so you can maximize all your benefits have to offer. Benefits are just that – a benefit of the job (equates to money). You probably know your company's bonus program well since that affects your bank account. Learn your benefits since that will ultimately affect the money you send out too! Here are a few steps I would recommend so you can begin this “education” on benefits:

Request a Summary Plan Description

This is also known as an SPD. You can obtain this from either your company or the insurance provider directly. This SPD explains in full detail what is/isn't covered in your plan. If the company tries to say they don't have one, they're unaware (which is typical). They must, by law, provide you with a copy of an SPD.

Review, Review, Review your EOB and Bills

It's so easy NOT to do this, but absolutely review your EOB's as soon as you receive them. Don't just check to see that the insurance paid a portion. Do the math to ensure the portion they paid was correct in the correct network and that any monies due by YOU has been added to your Deductible AND annual Out of Pocket (OOP) Maximum total!

Some plans have a Deductible and Out of Pocket Maximum (OOP Max). Each amount is different for an Individual or a Family. Once the Deductible is met, the Plan pays kicks in to pay (ours is 80%). Once the OOP Max is met, the plan must pay it's portion too (ours is 100%).

Here is an example of why this is important. I recently found that our insurance company paid on a procedure, but in that bill the insurance company took a network discount which is typical when they have agreements set up with certain providers. We received the bill from the provider and it stated we owed the amount that the insurance showed as unpaid (which was correct) PLUS the exact amount of the discount that the insurance company took (not correct).

I almost didn't connect the two but because I had been keeping a spreadsheet of all expenses for this specific procedure, I noticed my columns didn't add up. When I discussed this error with the provider, she stated the insurance company processed the claim in a network that wasn't eligible for a discount, which was wrong since that provider WAS in the network eligible for the discount. The provider suggested I call the insurance company and request they re-process the claim under the correct network.

Luckily, my insurance company paid a prior claim to that same provider just weeks before under the correct network so I knew the insurance company could do it. I called our insurance company and requested they re-process the claim.  It then became a chore of the insurance company fixing what they did wrong in the first place. The CSR stated she would send it to an analyst for review and call me back in 14 days to see if it was eligible. As I mentioned before, I knew it was eligible since the insurance company just paid that same provider a week prior under the correct network which received the discount.

14 days later and NO call.

I call back and was told they were waiting a response from that CSR who was supposed to call me back. Luckily, I got a good CSR the second time I called who was able to resolve the issue for me and my claim was re-processed under the correct network.

The reason this was important to correct and resolve was because any monies that came out of my pocket should be applied to the Out Of Pocket Maximum Total (for both Individual and Family). And, depending on your OOP Max, an error of $100 can make a huge difference of payment at 80% or payment at 100%.

Keep impeccable notes!

See what happened above. I was able to call back and tell the new rep all the details of what happened before. In general, I write down the person I spoke to, the date, the time, exactly what they quoted me and anything else that would be important. I even attempt to paraphrase our conversation.

If you do get into a situation where you find conflict with what was discussed in a prior call and the information you recorded from your notes, request that the insurance company pull a recording of the call so you can hear exactly what you were told. You might be wrong, you might be right, but know that they have access to that information (most places anyway) and have the capability to pull everything that was discussed.

I hope these tips help you. We pay for our family benefits and I need to be knowledgable about what we pay for. You wouldn't go make a major purchase and not do the research. You can't do that with your benefits either. Read up! If you are able to attend a Benefits meeting at your or your spouse's workplace, do it. The information will help you better manage your benefits and ultimately save your family money!