Quick notes

  • Talk to your insurer first before paying a “surprise billing”
  • Doctors might be advocate for you if an insurer refuses to cover a service
  • Leave a paper trail when communicating with your insurer

 
There’s nothing more frustrating than arguing with your health insurer. Unfortunately, it’s something most health care consumers have to deal with when it comes to things like surprise billing or figuring out what the heck their coverage includes. Here are a few things that may help during these difficult interactions.

You might not be liable for surprise billing

Surprise billing happens when “families receive out-of-network care due to no fault of their own,” says a statement on health care advocacy organization Families USA’s website. Although patients might attend a hospital that’s within their network, the providers within the hospital might not be under the same network. Having a patient interview each provider they interact with during a hospital visit is a difficult task …

So what can be done? Cheryl Fish-Parcham, director of access and initiatives at Families USA, says it depends on your state and the particulars of said state’s legislature.

“It would certainly be advisable for any consumer who has a surprise bill to talk to their state insurance department and find out what’s the remedy in their state,” says Fish-Parcham.

There might be protections for you or protections currently being developed at a legislative level. According to a 2019 brief from Families USA, some states have bills relating to surprise billing currently in session. For example, New Mexico passed SB 337, aka the Surprise Billing Protections Act, in April 2019 to take effect January 1, 2020.

A doctor might be able to advocate for you

There are some cases (let’s face it — there might be a lot) in which an insurer might not cover a treatment because they don’t believe it “medically necessary.” Doctors might be the secret weapon you need to get your insurance company to change its mind.

If a patient wishes to get a certain treatment covered, Fish-Parcham recommends filing an appeal with a provider involved in the process. In a Health.com article, retired surgeon James Moss, MD, told the publication he’s pressured his state insurance board in order to cover some patients’ treatments.

Insurance companies may not respect you or your doctor, but they will (or should, if they know what’s good for them) respect the board.

When in doubt, ask!

In my personal experience, I’ve asked a doctor to prescribe me alternative medications when my insurance company wouldn’t cover the first one he recommended. Everyone’s provider is different, of course, but thankfully mine was familiar with the intricacies of insurance and was able to get me an affordable option.

Patients may be able to call their insurance representatives and ask if there’s a generic version of the drug that they can cover. But there are some cases in which there ain’t nothing like the real thing (i.e., an alternative or generic won’t help you).

“You might consider an appeal about their formulary and whether they can make an exception for you,” says Fish-Parcham on how to get drugs you need.

Leave a paper trail

Having letters or emails from you and your insurance company makes it easier to keep track of your issue and helps hold them accountable. Fish-Parcham recommends calling a representative, however, because it is easier to solve issues with a conversation.

“(Patients) should then follow up by either keeping notes of who they talked to and what they said,” says Fish-Parcham. “Then sending an email or a letter saying, ‘This is what I understood from our conversation.’”

If your insurance company contradicts a previous conversation, you can always refer to your letters, notes, and emails.

You’re guaranteed certain protections …

Established March 23, 2010, the Affordable Care Act (aka ACA, aka Obamacare) requires insurance companies to have certain protections and coverage in effect. Some protections that health insurance plans must provide are coverage despite pre-existing conditions, free preventative care, mental health and substance abuse services, and more. There’s a comprehensive list on HealthCare.gov.

If a company isn’t complying, it’s important for them to be reported to a state insurance board.

… Unless you purchase a short-term, limited-duration health plan

“If you’re buying a policy that complies with the Affordable Care Act you can be guaranteed of certain benefits,” says Fish-Parcham. “If you buy a policy with the short-term, limited-duration plans, you’re not guaranteed those benefits.”

In August 2018, the current administration made it legal for insurance companies to sell short-term health plans that last for longer periods of time. Prior to this, short-term plans were only available for three months, but now they’re available for up to 364 days and renewable for up to three years, says a Families USA press release.

Critics of this move call short-term insurance plans “junk insurance.” The moniker is due to the fact that these plans are cheaper options on the marketplace but aren’t required to offer protections put into place by the ACA.

‘Difficult’ doesn’t mean ‘impossible’

Dealing with a giant health insurance company is daunting, but it doesn’t have to be impossible. You can try some of the methods above or hire a health care advocate to take on the insurers with you. We all could use help every once in a while!

A deeper dive — Related reading on the 101