Health Insurance in the United States is complicated and expensive. Even if you are one of the more fortunate American’s to have coverage that doesn’t mean things are simple or cheap. This is my brief guide to navigating the system for those who aren’t afraid of a few phone calls and details.
Until recently I had been on my parents’ and university’s health insurance programs. I recently switched to my own health insurance plan sponsored by my employer. I moved to a new city this month and knowing that I had health insurance wanted to get a new primary care physician.
When I signed up for my insurance plan with my employer I was given a choice of different plans. The difference was the monthly cost that I would have to pay in exchange for a higher deductible. Since I am young and healthy, I decided to go with the cheapest plan, with a higher deductible. This was a United HealthCare High Deductible Health Plan (HDHP) with a $3000 deductible. I assumed this was a pretty good plan and would cover routine preventative care.
Things weren’t so simple. After I made the appointment I wanted to confirm my coverage. I called the number on the back of my health insurance and asked about my coverage. My insurance provider said they couldn’t give me any exact information unless I had the procedure codes from the doctor’s office.
Determined to figure out exactly what I would be required to pay before I went into the office, I called the clinic where I had my appointment. I asked about the procedure codes. After being transferred to the billing specialist it was explained that there were a few different possibilities on how my appointment would be billed.
Since I was new at the clinic it could be billed as a new patient appointment or as a physical. A new patient appointment had five different options each with a different procedure code.
99201, 99202, 99203, 99204, and 99205, respectively for the five levels. I was told that 99201 and 99202 would be too basic, but unless the doctor needed to spend a lot of time with me it likely wouldn’t be a 99205. A bit of Googling reveals that the differences between these codes is the difficulty in the medical decision making. A 99201 and 99202 state the procedure requires “straightforward medical decision making”. 99203, 99204, and 99205 require medical decision making of low complexity, a moderate complexity, and a high complexity respectively. I guess the clinic gets to decide on which code to bill.
A physical was billed with the procedure code 99385. The clinic told me I would likely be billed as a new patient with a 99203 or 99204.
Armed with exact procedure codes I got back in touch with my insurance provider. Any new patient exam (99201-5) would not be considered routine preventative care. It would be covered under my policy at 90% only after my deductible was met. Since I had not used any of my deductible up, it meant that this new patient appointment would end up costing me between $300 and $500 dollars out of pocket.
However, a physical billed as a 99385 would be covered at 100% without any copay as routine general preventative care and would not go towards my deductible.
So simply depending on what number the clinic decides to bill my insurance with decides whether I have to pay or not. I called back the clinic to see if I could get a physical appointment billed as a 99385 instead of a new patient appointment. After being passed around and a someone asking the doctor I was told that yes, they would be willing to simply bill it as a physical with the 99385 procedure code. They said I’d need to be sure to remind the doctor to bill it as such during the appointment.
These phone calls probably saved me $400 dollars in fees. The clinic and doctor were happy to bill it so that my insurance would cover it, but they needed to be told in advance and have it confirmed.
I wish healthcare worked where you would know what you were going to be required to pay before going in, not afterwards.
So my suggestions for others are to be sure to get the procedure code from your physician, and then contact your insurance provider with that procedure code to figure out your coverage. If you end up with a bill that you were not expecting later on you can usually get voice transcripts from your phone calls and use those to file an appeal. If you were told that something would be covered, your insurance will be (likley) required to actually cover it.
I’d love to see a startup tackle this problem. I don’t want a healthcare insurance marketplace, I want a healthcare marketplace. I want to be able to shop online for my physical, for my broken wrist treatment, for my ACL surgery. This is like amazon.com where you don’t get to know the prices for the things you buy. It’s absurd.
blog comments powered by Disqus