Insurance Policy considerations [6-24]

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It's important for patients to be well-informed when it comes to their healthcare insurance plans

By Kennedy Tesch

Healthcare insurance plans can sometimes be frustrating and cause issues when it comes to patient care. The Hendricks Community Hospital Association wants patients to have a better understanding of their health insurance plans and options.

According to Kathryn Christensen, HCHA DNP, NP-C, it is important for medical providers to have a good awareness of insurance practices to help develop the most appropriate treatment plan for each patient.

“While we do not know the specifics of each insurance policy, we need to be aware high deductible plans, co-payments, and formularies in order to help our patients be treated the most appropriately while considering costs to insurers and patients,” Christensen said. “Providers also need to be able to find a balance between keeping costs low and providing appropriate care which can often be a challenge.”

A common issue Christensen often sees is her patients dealing with coverage issues for medications. Each insurance plan has a list of medications they cover called a formulary. Often, if there is a medication she wants to treat a patient with, it is required to choose something that is on the formulary or complete an appeal to see if they can get the preferred medication covered.

Christensen said patients should also be aware that often a prior authorization is needed for tests and procedures. These prior authorizations can take several days and are required before a test or procedure can be performed.

“Sometimes, if we feel a test is too important to wait, we will have patient’s sign a release stating they understand that it may not be covered,” Christensen said.

Another issue is that patients often are dealing with coverage based on what is “in-network.”

“I have had patients who end up changing clinics/providers due to their plan limiting network coverage which is unfortunate,” Christensen said.

Although there has been a lot of research on the best healthcare payor system, Christensen feels that due to the complexities of healthcare and ethical concerns, there is no ideal system. This is why it is crucial that patients take an active role in learning about what their healthcare insurance offers them.

The most important part of being a consumer is to be informed. If you have the ability to pick between different plans, review each thoroughly for premium costs, deductibles, out of pocket costs, and in-network providers. Patients should also be aware that lower premiums often correlate with less coverage and higher deductibles, co-pays etc. If you are on medications you take on a regular basis, review the plans formulary and prescription drug coverage as well.

“I often tell people the saying “you get what you pay for” often holds true when you are shopping for insurance plans,” Christensen said. “If you do not have the ability to select your plans as they are selected by your employer, let your employer know your concerns so they can consider alternative plans in the future.”

Tammy Niehus is the nursing home, hospital and Lincoln Lane Villa (LLV) billing manager at HCHA. In her role, she is responsible for submitting claims to the patient’s/resident’s carrier when needed. She also works on obtaining prior authorizations from patient’s insurance companies when services require prior authorization.

Niehus says the days of patients having Medicare and a supplemental insurance, or a basic commercial insurance carrier are long gone. Medicare has an annual Part B deductible and a Part A deductible. Medicare also generally only pays 80% for most services, leaving a 20% balance of the billing.  A Medicare supplement will pick up these balances. Medicare supplements will be an additional cost to the insurer.

“Due to rising costs, patients are having to shop around for the insurance carrier with the lower premium that they can afford,” she said. “With many Medicare aged individuals now choosing a Medicare Advantage Plan vs Medicare plus a supplemental insurance has caused many problems and frustrations for healthcare facilities. These policies require many things to be authorized prior to service, and many times, they deny the authorization of a service, resulting in the patient not receiving a service their medical provider has ordered.”

For example, a patient is seen at the clinic and the doctor orders a CT scan.  A prior authorization is submitted to the insurance carrier, and they deny it, stating it does not meet their medical necessity requirements. The patient can then only have that CT scan if they pay for the service themselves. Hospital inpatient stays have also become very difficult to get approved by Medicare Advantage Plans. 

“As a facility, we have unfortunately had several hospital stays denied, therefore, we receive no payment,” Niehus said. “We have also had to delay accepting patients in the hospital due to waiting to ensure their insurance carrier will approve the stay and pay.”

As insurance premiums continue to rise, patients are having to do a lot of research into what they can afford. 

“With that being said, choosing the insurance carrier with the lowest premium isn't generally the best option.  As with anything, you get what you pay for.  The patient will have a high deductible and/or limited coverage with the least expensive premium,” Niehus said. “Of course, as a facility, we would love to see that all Medicare aged patients have regular Medicare and a supplement to ensure they receive all treatment and services ordered by their provider, but we also understand that there are costs associated with this and that not every patient can afford that option.”

When costs are not covered by insurance, it is important for patients to understand that it is not the facility’s fault.  There are times a service cannot be provided without the patient paying out of pocket.

“It is a frustrating world for both the healthcare facility and the patient,” Niehus said. “We are struggling to ensure the best care for our patients but unfortunately the insurance companies are now dictating healthcare, not the medical providers.”