When phoning the insurance company about enrollee benefits and the schedule of allowable payments, it is important for the patient to have the policy and group numbers from her insurance card in front of her. Callers typically encounter many programmed responses and holds. When an actual person is reached, even the most pleasant and consumer-oriented insurance company representative is often unable to explain the allowable payments for a specific service or specific physician. Typically, the representative will tell the patient whether the doctor or clinic is in or out of the health plan provider network and refer the patient to a website.
Encourage your patient to ask the insurance company these important questions:
• Does the insurance plan have a restricted provider network of clinics or doctors? If so, when are these network clinics/physicians available to see me? What coverage is available if I decide to use physicians or clinics that are not in the provider network? It is very important for the patient to contact the clinic directly to see if and exactly when one of its physicians can see her.
• What is the insurance plan deductible, and how do I satisfy the documentation of medical services that apply to satisfying the insurance deductible amount? Either the clinic or the patient submits the clinic charges using current procedural terminology (CPT) codes. Following submission to the insurance company, these charges are first "denied for payment" by the insurance company and then are accounted toward satisfying the enrollee’s insurance deductible.
• Does my insurance plan cover this health service? For example, there are often strict limits on mental health and chemical dependency care, despite Minnesota and federal mental health parity legislation. Most Minnesota health plans, for example, require treatment at in-network mental health or substance abuse clinics or programs, even though none may be available.
• Are there providers in the network who are appropriately trained and available to see me? The health plan will refer patients to its website so they can search out names and locations. Patients should insist on getting personalized help from their health plan or insurance company to connect with an available provider suited to their particular medical needs, since availability is part of an insurance contract.
• Do medication copayments qualify toward satisfying the insurance deductible? And how are they to be accounted? The insurance company should know this. Medications are handled by a pharmacy benefit manager (PBM) company, so the patient will need to go to her retail pharmacy (armed with her insurance card) to learn about medication copayments and restrictions, as explained in the section below.
Pharmacy Benefits
When asked about prices, community pharmacists quote their retail prices for medications they have on hand or dispense. They can, however, readily check on the out-of pocket cost of a given medication for a specific patient if they have the insurance information. With a swipe of an insurance card, the pharmacist can instantly find out from the patient’s health plan pharmacy benefit manager (PBM) what the patient must pay at the pharmacy.
Patients should know that, armed with their insurance card, they can check with their pharmacy about which drugs are on your insurance plan formulary that pertain to their care needs. The formulary is a list of prescription drugs, both generic and brand name, that are covered by their health plan. The health plan will pay for a portion of the pharmacy cost, but the amount of coverage varies greatly. Patients need to get the specific details of their copayments directly from the pharmacy. I recommend that they do this before the physician or prescriber writes or renews their prescription.
Knowing the actual cost of a medication is a big deal for our patients. After all, if patients cannot afford medications, their prescriptions are likely to go unfilled or to be insufficiently dosed, which in turn leads to poor treatment outcomes. A recent Consumer Reports survey showed, unsurprisingly, that patients do not follow our recommendations when they believe they cannot afford their medications.
When it comes to shopping for health care insurance, encourage patients and their families to consult a qualified independent insurance agent to discuss their health care insurance options. This proactive approach on the part of patients will help relieve a lot of their health care cost anxiety.
Dr. Lee H. Beecher is president of the Minnesota Physician-Patient Alliance and a psychiatrist in private practice in Minneapolis. He also serves as a member of the editorial advisory board for Clinical Psychiatry News, a publication of Elsevier.