Self Advocacy: How to Fight for Your Right

The current climate of insurance is a confusing plethora or terms and conditions, of difficulties and challenges. 

This post will touch on some basic tools and concepts that might help you and your family understand and navigate the field.

Regardless of how you are covered, insurances' basic concept is you pay for them to cover your bills later on.  Most private insurers are also businesses.  So, they want to make a profit.  How do they do that?  They take money in from you (the covered person) and a lot of them get subsidies from the government.  

As a patient, you need to make sure that you are getting the coverage you paid for.  When you see a new physician, make sure you call the insurance company and check to see if your new doctor is in your network.  This is something basic they should be able to tell you.  If the doctor is not, check with the doctor's office to get a feel for the fees you might be charged.  

Something else to see is if your policy has out of network benefits.  This means that if a doctor is not in your network some of their charges might be covered.  

Why do not all doctors take all insurances?  Sometimes the insurer and the doctor cannot come to an agreement about fees paid for services.  Other times, the insurers will not contract with physicians for different specialties in order to control their costs.  

Your premium is the monthly amount you pay the insurer for your policy.  

Copayment: This is the cost-sharing part of your bill that is a fixed dollar amount designated by your insurance company that is your responsibility to pay at each visit (also known as a copay). Be aware that copayment rates vary from insurance company to insurance company.

Deductible: This is the amount of cost-sharing that you must pay for medical services, often before your health insurance company starts to pay.

Coinsurance: The part of your bill, in addition to a copay, that you must pay. Coinsurance is usually a percentage of the total medical bill—for example 20%.

If you need guidance, the representative from the insurer should be able to answer most questions.

As a patient, there are times where the insurer might give you different information than they gave your doctor's office.  It is important to document the time you spoke to the insurer, the name of the representative (or their operator number) for verification purposes.  

On rare occasions, the insurer may give you or your doctor incorrect information.  We recommend you escalate the issue quickly by asking to speak to a supervisor.  You are your best advocate!  If there is still an issue, consider filing a complaint with your state Insurance Commissioner.  

It's your insurance, it should work for you.

Author

Brian R. Gantwerker, MD, FACS, FAANS Brian R. Gantwerker, MD, FAANS, FACS specializes in the treatment of degenerative and traumatic diseases of the spine through minimally invasive techniques. He also treats many patients for concussion and its after-effects and educates on its prevention. Dr. Gantwerker is committed to providing newly advanced techniques for the treatment of brain and spine diseases. He is proficient in both minimally-invasive and complex brain and spinal surgeries. He is diplomate of the American Board of Neurological Surgery. Dr. Gantwerker is a Chicago native who attended the University of Illinois at Urbana-Champaign where he earned his pre-medical education and graduated magna cum laude with honors, majoring in psychology. Dr. Gantwerker received his medical degree at Rush Medical College in Chicago where he focused on peripheral nerve regeneration research. Dr. Gantwerker is a member societies, and a member of the CNS, AANS, and serves as a director at the California Association of Neurological Surgeons.