"Know" Surprises with Health Insurance Plans-HMO

Today, the discussion is related to HMOs. Today's HMO has evolved over the years. Referring back to my previous post, you will recall that there was a battle between providers and the insurance companies which greatly contributed to cost increases (in my opinion). The payment for services was largely uncontrolled. In other words, as the cost of care increased so did the payment. It didn't take too many years until the payers began an attempt to control how care was delivered in order to control costs. The HMO and Managed Care was born.

The HMO (Health Maintenance Organization) in it's most strict time, placed heavy restrictions on the setting for care (hospital, MD office, home) as well as the cost. The concept was that an exclusive network of care providers was created by payers. The providers would accept deep discounts on their reimbursement in exchange for guaranteed steering of patients to them. The impact on you is that you MUST use providers within that network or you pay a much higher price. Additionally, each person was to have assisgned a "Primary Care Physician" who was considered the gatekeeper for directing what care you did receive, i.e. referral to specialists, etc. The philosophy is that there would be one person/physician that would be in a position to keep the pieces of your care coordinated. Did it work?? For the sake of discussion, no it did not. The ultimate result was that there was too many services, too few primary (family) doctors and too many specialists.

Ultimately, the Managed Care concept met too much resistance to actually contain costs. The care was still passed around to specialists and there was not much actual coordination of care...just control of care. Over time, care became more fragmented as new technologies and treatments continued to attract people to multiple specialists and increased the costs. It has become "Managed Cost resulting in Mangled Care".

The HMO still exists today, but really the only thing that resembles the original HMO is the network of contracted providers. You must use those providers or pay a higher cost. A primary physician is usually no longer required...why would it be...it didn't work anyway. In fact, the HMO doesn't really look all that different from other popular types of coverage plans such a PPO (Preferred Provider Organization). The KEY for you is to read your policy carefully...some items will be covered and some will not and circumstances may dictate whether care is approved. Let's be clear...the payors are not dictating whether you can receive certain care but whether they will pay for the care. That's another set of posts. In the meantime, stay Healthy and Happy. alice@EZHealthCareOnline.com http://www.ezhealthcareonline.com/

"Know" Surprises with Health Insurance Plans

I am going to discuss the different types of health insurance plans in the next few blog posts. If you have an employer sponsored health plan, there may be different options presented to you. If so, you really need to understand how they work so you can make the best selection for you. If you are purchasing individual insurance, it is really important to know what you are purchasing.

Today we are going to talk about the traditional "indemnity plan". This is what most people experienced in the early years of health insurance. Although it is not common to see this plan in today's healthcare market, it is good to understand how it works in order to help build the understanding of the evolution in health insurance. These plans are generally very simple. There is no restriction on the choice of doctor or hospital. For most encounters, you will pay a fixed percentage of the health bill. Common co-insurance (the part you pay) runs from 10% to 30% although it can be any number. Be sure you know what your co-insurance will be...a large bill could surprise you with a large part to pay.

On the other hand, the insurance company will pay either 90% or 70% respectively. While insurance companies have allways had contracts with health providers (as far as I know) to discount their services, the providers would increase their charges to off-set the discount. An example of this might look like this: a $500 dollar service would be discounted to $400. It would cost the insurance 80% ($320), cost you 20% ($80) and the provider collects the entire discounted $400. Then, so the provider can collect the total $500 for the same service the prices would be raised by 25%. The scenario then becomes 80% ($400) and 20% ($100) and the provider collects $500. Within these scnerios, note that your actual cost is higher. These scenarios have occured repeatedly through the years. The more the cost the more that the provider collected from you and the insurance company.

This cycle of increased pricing to off-set the insurance discounts, is in a big part the stimulus for creating other ways of negotiating and pay healthcare costs. That brings in the HMO and the term managed care. Refer back to the primary title of my blog as to how that played out. Our next discussion will be on HMO,

Keep Your Dollars in Your Pocket: Bargain With Your Doctor

A recent WebMD article was listing ways to save money on your healthcare. The timing on this is excellent, since this has been our main discussion topic for several posts. The suggestion was given to bargain with your doctor. This is a topic I typically have on my list of suggestions also. When is this appropriate and how do you accomplish it? If you are going to be paying the entire cost of your visit, procedure or test, this is prime time to ask for a discount. The physician’s office will usually ask about your insurance as they are scheduling your first appointment. I recommend taking a very proactive and positive response to this question. Rather than just stating that you do not have insurance, tell them you will be paying cash. Explain your situation. WebMD suggests saying “You’re not in my network, but I wouldn’t trust anyone else to handle this. Is there any way you can adjust your fee for me?” You just might be surprised at what you hear. If you approach it carefully, develop a positive relationship with the physician and the staff, there is a high chance you will have a positive outcome. The physician (and hospitals or surgery centers) can adjust their fee for you and still come out with a larger payment than if you did have insurance (usually). If they believe that you will pay, it is more likely they will be willing to discuss it. It is fairly routine for a health provider to give a 20% discount. Most can go less than that and still make a nice profit. When they negotiate with an insurance company, there are steep discounts plus the member’s co-pay of only 20-30 dollars. So now you know that you have some room for negotiation but don’t try to force a steeper discount or you may get none. Remember, a good relationship with the health care provider is your best negotiating tool.

One last reminder. If you are negotiating with a facility (hospital, surgery center) do not pay your bill up front. You can save more money by examining the detailed bill. There are companies or people that can help you with that task. I can hook you up, give me a call. alice@EZHealthCareOnline.com www.EZHealthCareOnline.com