They likely understand just as much — or as little — as you.
This article is part of an ongoing series providing insights and tips from a primary care doctor on how to get the most from your medical appointments, what your doctor might be experiencing on the other side of the exam table, and all that patients and doctors have in common, so we can make the best of our healthcare system together.
As a primary care physician, one of the most common questions my patients ask me is, “Will my insurance cover this [insert test/medication/specialist]?” And I get it — nothing is worse than undergoing endless tests only to receive a surprisingly steep bill in the mail a few weeks later. I’ve heard from patients and friends that this is far too common of an occurrence.
My reaction to these questions is always the same, and it’s often a surprise to both my patients and friends: Most of the time, physicians don’t know what services will be paid for by a patient’s insurance plan. It’s hard to believe — how can a medical doctor be in the dark about something as important as how much a person will pay out of pocket for the services they provide?
There’s so much that patients and clinicians have in common, and it turns out that this is one of our biggest areas of overlap. It can be incredibly hard — for all of us — to understand the ins and outs of insurance coverage. Here are some reasons why, and tips and tools to navigate this complicated terrain a little more confidently.
Doctors don’t always know what your insurance covers
The first reason why your doctor may feel as perplexed by insurance coverage questions as you do is inadequate exposure to this topic in medical school. Recently, there has been a push to enhance medical school curricula with more education in healthcare financing and economics, to help future doctors feel more confident in discussing these topics with their patients. Even with additional training in this area, chances are your healthcare provider will be more comfortable managing the medical aspects of your care than the financial ones. And that’s not a bad thing — you want your doctor’s expertise to be in diagnosis and treatment, not billing. But everyone’s lives would be a little easier if the practitioner were ever so slightly more insurance-informed.
Similarly, when clinicians spend time keeping up to date with the medical literature, we tend to focus on the more scientific, clinical articles that pertain to our patients’ health, rather than constant changes in the insurance landscape. Again, that may be for the best.
When I was a new physician, fresh out of residency training, I made an effort to learn what my patients’ different health insurance plans covered for different kinds of visits. I soon learned that what was covered (or not) changed so quickly that it became impossible to keep up. My patients share this same sentiment with me all the time. If it’s difficult for a person to keep up with their own plan, you can imagine how challenging it is for any doctor to keep up with hundreds of patients’ plans.
One final reason why this topic can be as challenging for clinicians as it is for patients is that doctors’ offices don’t have special access to insurance plan representatives. Many of my patients have thought that it would be more straightforward for me to contact their insurance plan to resolve a certain dilemma or dispute instead of them because they thought I might have a direct line or a special contact person. This would be a dream! When I reach out to an insurance plan, even when I choose the phone tree option saying I’m calling from a doctor’s office, I end up spending just as long on hold as I do as a patient. Direct, speedy access to a solution would make both my life and my patients’ lives easier.
With all of this in mind, there are still strategies each person can use to navigate the complex, often deeply frustrating healthcare system. Here are some tips and tools to better understand what your insurance plan may cover.
- Contact your insurance plan and obtain a copy of your Summary of Benefits and Coverage (SBC). According to the Centers for Medicare and Medicaid Services, an SBC is “a snapshot of a health plan’s costs, benefits, covered health care services, and other features that are important to consumers.” Its information is often presented in table form (see here for an example), and it can take a little bit of time to wade through and digest. However, getting to know the SBC will provide a helpful foundation of knowledge regarding which medical services are or are not covered.
Examples include the amount of your annual deductible, what your copay may be for different kinds of doctors’ visits, whether you need a referral to see a specialist, and how much your plan may cover for services like mental healthcare or prenatal care. This can change each year, so you may need to request a new SBC to stay up to date.
- Tap into other resources offered by your health insurance plan. For example, your plan’s website should have an online, up-to-date drug formulary, where you can find out which medications are covered and which ones may be more expensive. Many plans publish healthcare cost transparency tools, where the prices of different healthcare services are posted publicly. Similarly, most plans publish information on which healthcare providers are covered “in network,” versus those who are “out of network” and would cost more to visit. Make sure to check your insurance portal when booking a visit (even if they say “In Network” on ZocDoc, crosscheck to play it safe) and look for the in- and out-of-network labels. Nothing’s worse than waiting months for a doctor’s visit only to find out they don’t actually take your insurance when you arrive.
- If your doctor doesn’t know the answer to your insurance-related questions, someone else in their office might. Most medical offices have a staff member who is prepared to answer questions about insurance and billing. This may be a billing coordinator or an office manager. Ask your clinician who else you should turn to for more information.
- Feel empowered to educate your physician about what was covered — or not — from a past visit. I feel grateful (and also remorseful) when a patient tells me that a blood test I had ordered wasn’t covered by insurance. This candor allows me to look back and determine what I can do differently in the future. It may be as simple as using a different diagnosis code to justify why I’m ordering a particular test. This information-sharing can also help other patients down the line.
- Speaking of diagnosis codes, if you have a chronic or recurring illness, it can be helpful to know what your main diagnosis codes are — even just the names of the diagnoses. Thanks to the 21st Century Cures Act, patients are allowed to access their medical data, including healthcare provider notes. Reading over your healthcare information will allow you to see which diagnosis codes come up over and over again (for example, “essential hypertension” or “iron deficiency anemia”). Your clinician uses these codes to demonstrate to insurance companies why they’re ordering specific tests or referring you to certain specialists. Being familiar with this terminology can help you ensure that future medical visits and tests are being billed appropriately.
- Sometimes, your insurance plan will ask your healthcare provider to complete prior authorization paperwork for a particular medication or imaging study. Prior authorization, often shortened to “prior auth”, is a series of forms that a clinician must fill out to essentially plead with the insurance company to pay for a service. Clinicians are known to loathe the prior auth process; it can take hours of medical office staff time per week, lead to unnecessary delays in care, and frustrate patients and doctors alike when important tests or treatments are denied. If your doctor needs to complete prior auth paperwork for you, you may be able to help them fill out the form as thoroughly and accurately as possible. For example, did other antidepressants not work for you in the past? Is your knee pain still debilitating, even after working with physical therapy for three months? Telling your doctor what you’ve tried — and what hasn’t worked — will help them make the most compelling case to your insurance plan.
It’s important to note that these strategies apply to the roughly 300 million Americans with health insurance. There are another 27.6 million Americans without health care insurance. Healthcare.gov can be a helpful resource for finding a new plan from scratch.
Insurance coverage can be a thorny issue for both patients and their doctors. Learning which resources are available to us, and understanding each other’s perspectives, can help reduce frustrations from visit to visit and allow us to collaborate as successfully as possible.
Neda Frayha, MD, is a primary care internist, editor, and host of the Primary Care Reviews and Perspectives podcast by Hippo Education, and public radio contributor on topics related to health and medicine. She has written for the Washington Post, reported on health care for WHYY, and been featured on podcasts such as The Pulse, The Broad Experience, and The Curbsiders.
