Wednesday, August 15, 2012

Insurance 101

I have no idea if anyone will read this but my god I hope so because that will mean that I may have helped someone out there.

Saturday I had a dental procedure done which was step one of a pretty lengthy process.  Of course they verified my benefits and what my liability would be.  After paying them over $700 in less than a month I finally had time to do some research and VOILA they are robbing me! They are crediting on the fact that I will not research and find that they are not only over charging me but collecting money that IS NOT due to them!  This is where I am thankful for those years as a call center representative at an insurance company and those years spent planning curriculum training call center reps the ins and outs of policies. 

So if ANYONE reads this who hasn't taken the time to find if their medical or dental provider (aka doctor) is robbing them, I hope this helps you!

Top 5 MUST DO's
1) ALWAYS read your Explanation of Benefits.  You know those annoying pieces of paper that pile up in the mail when you have a few doctor's visits, READ THEM! Even if you already do, keep practicing this because you never know where money has been collected that wasn't due. 

2) Understand how your policy works.  Not just what a deductible is and if you pay 10% or 20%, understand ALL OF IT.  If your doctor is in network, also make sure he/she is a contracting provider with your insurance carrier.  Majority of the time if they're in network, they're contracting, but just to be safe, double check this!  If your doctor is contracting with your insurance carrier that means that they agree to the CARRIER'S fee schedule.  So for example, if a doctor charges $100 for a service and the insurance company states their fee is $75.00, the doctor has to write off the $25 difference.  Case closed.  If they're contracting there's no arguing this. 

3) Do your research!!   If a provider advises you have to get a procedure done and they go over your "liability" with you before scheduling the procedure, RESEARCH!  Ask them for procedure and diagnosis codes so that you can call your insurance company and verify for yourself what will and will not be covered.   DENTAL coverage isn't influenced by diagnosis codes as much as medical procedures, remember this!   Especially with dental procedures, please get into the practice of researching!  This is how I found out what was going on with my dentist.  I assure you, it's worth the effort!  Allow me to share my situation :)
I was told that the extraction I had done would cost me $1075.60 and of course they wanted the payment up front.  Well I don't have that kind of money to throw around so they graciously (note sarcasm) broke it into 3 payments of $333.56.  Well b/c I was so nervous they gave me nitrous oxide to relax me which increased the balance a bit plus I elected to have the oral cancer screening b/c screening is always a good thing.  Anyways, I knew something wasn't right in terms of my liability and I really thought "MAN I have HORRIBLE dental insurance"  so I did some research today.  Turns out, my insurance actually DOES pay them for all of the services I had done AND my actual liability is only about $350 so THEY owe ME money back now.  REMEMBER THIS!  If a provider is willing to discuss your liability with you before you have the procedure and they want payment right away, RESEARCH!  I'm not saying all of them practice this way, but just be safe and protect yourself!

4) Please be kind to the call center reps (HAHA)  I say this b/c I was once one of them and trust me, they're not crazy about their job and they are simply just the messenger.  The people who answer your call don't process your claims and generally have pretty much no power to do much besides pass your complaint onto a supervisor, so please be kind to your reps :)  They're just making a paycheck to pay the bills.  Some of them are quite rude I know but kill em with kindness and be the better person

5) Never be afraid to let the provider know you'd like to verify your benefits. Don't ever let anyone bully you into trusting them.  As the patient you have the right to know what you're paying for and if what you're being billed is legit.  I've come across some staff members who didn't like that I asked for codes b/c I wanted to research myself but if they're practicing honestly, it shouldn't be an issue. 

I don't know if anyone will read this or find it useful but I'm putting it out there b/c A) I needed to vent and B) maybe someone out there WILL read this and it will help them.  Or they'll pass it on, who knows :)

That's all for now!


  1. Thanks for your post. I found really interesting.
    I have to look into my own benefits and do some research. I am not to sure if it's a different practice here in Canada than in the U.S.A. but it's worth a look.
    Thanks Sarah.

  2. If you need "help" just let me know :) I honestly don't mind at all, I don't see how it could be THAT much different between US and Canada so feel free to use my brain :)
    I'm glad my venting post helped haha I'm calmer today but still pretty heated :P