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Healthcare System Alerts and Warnings for 2013

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Updated January 02, 2013

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Health Insurance Providers - Making Reimbursement for Care More Difficult

As it has for decades, our care is getting more and more expensive. Now add that to the new squeezes being put on health payers as a result of the Affordable Care Act (public and private) and more than ever, those payers are keeping a tight grip on the money they do have, and not paying out anymore than they have to - and in too many cases, not even paying out what they are required to pay. Unless someone pursues that payment, the insurer just pockets the money and no one is the wiser.

Here is some advice to make sure your insurer is paying everything it is obligated to pay on your behalf:

  • Even if you have had an appointment within the last few months with a doctor (any doctor - primary or specialist), double check before your next appointment that the doctor still accepts your insurance. More and more changes are being made to reimbursement acceptances and patients are rarely notified. Your doctor may no longer accept your insurance, but you probably won't be told until after your appointment, leaving you with no choice but to pay for an out-of-network medical bill.

  • Make sure you have a referral from your primary care doctor to see any other doctor, even if you don't think your insurance requires it. Insurers have added to their fine print that they won't pay for any appointments, nor the resulting tests, diagnoses or treatments, that stem from an appointment they did not approve. Then, with no notification of the change to the fine print, customers find out in very abrupt ways that they will be required to pay for something they have never had to pay for previously.

  • Check your insurer's formulary (list of drugs and what they will cost you) after January 1, 2013 to be sure the drugs you have taken on a regular basis haven't been shifted into a more expensive tier. If they have, check with your doctor to see if you can be prescribed another drug, or a generic, that will cost you less.

In general, the best advice for working with your payer is to assume they don't want to pay for anything, even those things they are obligated to pay for. Get permission before you seek care, double check every doctor you see or facility you go to (from hospitals to urgent care centers), and if you aren't sure the insurance company is giving you a straight answer, or a fair answer, seek help from a professional.

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