How to choose family health insurance

I asked for Kerry Sorenson to come on with me today specifically to talk about health insurance and choosing the correct health insurance for your family, for your needs.

Welcome to Wellness in Every Season. We talk all things wellness regarding the environment that you spend a lot of your time in, your physical health, your intellectual health, your financial health, your spiritual health, professional health, your social health, who you have relationships with, your emotional health.

This is a really big umbrella, so expect all kinds of topics within all of these amazing dimensions of your wellness. Let's dive in

So for anybody who has not been listening for long enough to know this, I used to do medical billing and coding until I became a stay-at-home mom, and that was 12 years ago that I got out of it.

My oldest is turning 12. So back in ICD-9 land is where I was. Now it's ICD-10. Eventually there's gonna be an 11. But I would have people call my office and ask their primary care physician office is where I did medical billing and coding at this time. They would ask, "Which insurance plan should I choose?

I need help choosing it." So I would look in their file, see their age, and start to give them advice. And now I'm to the point where I'll have family members, and I don't know, 12 years out of the game. And things have changed, especially if you are older. It used to be I would know what plan to choose, especially for you to have primary and secondary, to have the best coverage possible.

I don't know that. I know that if you don't have as many medical issues and you're younger, you can get plans for cheaper, but there are so many variables in here. So that is why I have Kerry with me, and she is not going to sell you something. So here's the big difference. I found somebody who works for the University of Maryland, so she's right in my backyard, and this is what she does.

She helps people with this. And let me tell you more about her bio besides more of what I know. She is a community health educator with the University of Maryland Extension. As Kerry likes to say, she teaches everything people didn't learn in school, including how to navigate health insurance. Through the program Smart Choice, Smart Use, Kerry and other Extension educ- educators work to empower people with the information they need to feel confident navigating their health insurance.

Kerry has been teaching this program since 2017, and believes that although health insurance is confusing, yes, health insurance education can support people in getting the care they need at a price they can afford. So if you feel like you're good health insurance-wise, you still know somebody who doesn't, so share this episode.

And I also want you, if you're thinking, "Okay, I'm good health insurance-wise, but what about other insurances?" I got you. Look for those episodes. They're coming up. So Kerry, thank you for being on,

 Thank you so much for having me. I always tell people, I might be one of the few people in the world who's so excited to talk about health insurance. So I was really excited to get your invite, and I'm really excited for the conversation we're gonna have

Yeah, I'm so excited.

And she had to help me. I had 10 questions, and I had the realization that this is gonna be, two and a half hours long if we get through all 10 questions. So this will probably be longer than the 30 minutes, 30 to 45 minutes that I try to hit because, like I said, medical billing and coding background, what Carrie does, knowing that this is going to help people and that just a couple questions isn't gonna get us there I know that even with the amount of time we will end up using, you're still going to have more questions, so we will get you those resources as well.

So just hold on, listen up, or go to the show description if you can't wait and you'll find the links there.

So let's start off with the basics. When we choose a health insurance plan, what are the most important numbers and terms we need to understand? Can you walk us through premiums, deductibles, co-pays, co-insurance, and out-of-pocket maximums in plain English?

And I'm sure so many people are going, "What?" Especially I know I had so many people call on me and being confused about co-insurance versus co-pay in particular.

Mm-hmm. Yes. So yes, we can definitely talk about all that. And I love that you said plain English because that is a huge part of, I think, what's so confusing about a lot of this, is that what you don't understand, and then you start to go try and find more information about it, and it's the definition sometimes is even more confusing than the first step.

So we are gonna try to go through this step by step and explain this, in the most digestible way we possibly can. So that's where we're gonna, we're gonna work from. And I think the first place that you wanna start is thinking about the premium. So often that is kind of the first number you get hit with when you're signing up for insurance, and I think about it like a membership fee.

It's the amount that you're paying. It's a set amount. You usually pay it monthly, although there's some examples where you might pay it quarterly or yearly. that's the amount you're playing to, paying to be included in the plan. So it's I pay this fee, I'm a member, I'm part of the plan, I'm covered under this health insurance plan.

So at a minimum, we've got to be prepared to pay those monthly premiums. Usually for a lot... The majority of folks in the US get their insurance through their employer, so those are usually coming out through the employer deductions that are somewhere in your super confusing pay stub. but so that's where that's coming up.

So a lot of the time when people are picking a plan, that's the kind of most accessible number, 'cause it's "Okay, well, I know I'm going to get asked to at least pay this every month." And so a lot of the time people kind of look at that and say "Okay, well, I'm just gonna pick whichever one seems like the best fit for my budget."

and there are a few other numbers that you also asked about in your question that we gotta talk about to better understand what's going on with that premium and whether or not that's really giving us all the information we need to make a, an informed decision. So then we kind of move into the- Can I butt

in for one second?

Yes, absolutely. So

that same doctor's office that I worked for, they offered crappy insurance. So I just wanna do this quick Look around other places if you feel like the insurance where you work is offering you a terrible plan.

Yeah.

Because it might actually be cheaper for you to go out on your own. It was- I- I was young at that time, didn't have kids.

My husband had insurance through his dad still, so I just got a plan just for me, and it was a great plan

And that's true. I'm talking about this 'cause thinking about, comparing and contrasting, but a lot of people only have one offered through their employer. So yeah, if you look at that and you're like, "This is not seeming like it's gonna be a good fit," then yes, def- and we can talk about some of the other options that are out there for how people can look at other coverage options, too.

okay, so then the next piece we go into is, how do the costs work? And the deductible, the co-insurance, the co-pay, the out-of-pocket maximum, those are all telling you things about the plan in terms of what are you going to end up paying. and so super critical, but also things that confuse almost everyone.

When this comes up in research, it's like the majority of people are not sure what a deductible means. They're not sure what co-insurance is. So if you feel that way, you are not alone. So let's talk about h- what that kind of structure looks like. And I think about it as phases. So when you have health insurance, the cost structure kind of falls into three phases, and you kind of, you progress through them one at a time.

So your phase one is w- until you meet, that's the kind of terminology we use for it, meet your deductible. So the deductible is the amount that you've gotta pay out of pocket before your insurance plan is gonna start to pay for anything. and that's always confusing to people 'cause it's "Well, I'm paying the premium.

I'm paying to be a member. What do you mean now I immediately need to pay for something else?" so that, that deductible number's really critical 'cause it's every year, so it resets at the beginning of each year, and it's telling you how much you're gonna be asked to pay before any of the other stuff kicks in.

So that is our phase one, meeting your deductible. Once you've met your deductible, that's when co-insurance kicks in. and usually when you're looking at plans, they will tell you what the co-insurance percentages are. So they're gonna refer to it like 80/20, 90/10, 60/40, these different percentage splits.

And so what it's telling you is the percentage that the insurance company's gonna pay, and then the percentage that you're gonna pay. So once you've met that deductible, now we're gonna look at it and say, "Okay, the insurance is gonna pay a portion, and I'm gonna pay a portion, and tho- those amounts are gonna be decided by my co-insurance percentage."

and so that, again, very confusing, so I'll use an example here 'cause I think that that's really helpful. So let's say I have a $500 deductible, and I go to the doctor and the bill is $600. That first 500 is gonna be my responsibility alone. So I'm paying that $500 out of pocket. Now I've met my deductible, and then that remaining $100 is gonna be split according to the co-insurance percentages.

So if I have an 80/20 plan, then they're gonna pay $80 and I'm gonna pay $20. So in total, for that $600 bill, I'm paying $520. $500 to meet my deductible, and $20 for the remaining co-insurance. That's our first two phases. And I feel like maybe we should pause there and say, "Is it starting to make sense why this is so confusing for everyone?"

'Cause we're already doing math and we've just started talking.

Well,

here's the thing, is sometimes people, you can lose money if you don't understand this. And I have walked through... I've even had patients that felt comfortable enough with me that would come with their bills from other doctor's offices to have me look over it for them.

And they were usually elderly patients, just that doctor worked mostly with older, the older population, and they needed that. Yeah. They didn't have family members that could help them with that. And the biggest thing that I catch for myself with my family is that they will send me the bill when it's still during the deductible season, and I see that it hasn't actually gone to insurance because insurance has not written anything off.

Check your bills to make sure insurance has written something off. If they have not, call the billing office. Yes. Sometimes they don't put that on the bill. But 95% of the time they do. So call if you're not seeing something written off before you pay anything.

Yeah, and you'll get that-

Yes, go ahead.

Yeah, sorry.

You'll get that explanation of benefits that'll have that chart in it that has so much information, but that's exactly what it's gonna show is, okay, this is what the office billed, this is what the insurance adjusted it to, so that's when that allowed amount comes in, and then this is what you're gonna be responsible for paying.

So that adjustment should happen before you're being asked to pay for anything. so sometimes people, yeah, you're saying, they get a bill and they're "Oh, okay, well, I need to meet my deductible, so I must need to pay this bill." It's well, it's not always right, and so we wanna check and make sure that we are not being asked to pay any more than we should.

Even, even for a cost that we know we have to pay, we still wanna make sure that amount is right.

Right.

And, and so then our f- so that's phase two. So we've got phase one, we meet the deductible. Phase two, we split costs with our co-insurance. And then phase three is you've met your out-of-pocket maximum.

And so that's the amount that is the most you're gonna be asked to pay out of pocket during your plan year. And once you've met that number, the insurance is gonna pay for everything that is covered, and we'll get into that a little bit more, what we mean when we say covered. Everything that's covered after that point, the insurance is gonna pay for 100%.

So it's, if you think about it in the three phases, there's phase one, I pay; phase two, we pay; phase three, they pay. And those numbers tell you where those points are that you transition from one phase to another. and so when you're looking at the documents and understanding your plan, you really need to know the co-insurance percentage, the deductible, and the out-of-pocket maximum, 'cause they tell you so much about what your costs are gonna look like under the plan.

The only last one we didn't talk about there is co-pay. Let me just tell you, the number of times we decide to use a really similar term for two very separate things. so again, we're starting with co like we did with coinsurance. It's copay. It's a totally separate thing. And so the copay is a set amount that you pay for each service depending on what it is.

So usually it's gonna be listed on your insurance card, and there's gonna be one number for primary care, one number for maybe seeing a specialist or going to urgent care, and then another number for going to the emergency room. And that's usually in order of cost, too. So your primary care is gonna be the least expensive copay.

Your emergency room's gonna be the most expensive copay. but the key to keep in mind with that is that it's a set amount, and it's usually something that you pay when you go to the doctor's office. They're usually gonna ask for it upfront. Whereas the coinsurance is a percentage that's calculated based on the services, and you get that bill later on.

So hopefully that helps explain the difference between those two exceedingly similar terms.

And with coinsurance, the only place that they charge you ahead of time is if you are going... If you're in Maryland, Community Radiologists, they're a huge name here on the East Coast. So if you're going for X-rays, mammogram, if you're seeing a specific specialist they may, but it's getting a procedure done.

They're going to collect the coinsurance ahead of time. But a doctor's office, give them frown if they try to do that. They should not be doing that.

Yeah.

So how many insurance companies really use copays anymore? Feels like hardly any of them do it anymore.

The majority of the ones that I'm familiar with still have copays.

Some of them have programs where they may be, they have a $0 copay for, your primary care or if you engage in certain wellness plans and things like that. So, if you get your annual checkup, we'll do $0 copays. and usually the copays are maybe 15, 20, $25. so they're... And, well, except for the insur- the, emergency room ones go a little higher.

so that's usually where we see those. I would say we see them, often we see situations where they're either waived or discounted. but especially for specialist visits and emergency room or urgent care visits, y- there's typically gonna be a copay there.

Perfect. And then I really like this next question because, let me tell you a little bit and then I'll ask the question.

So my husband, he, he knows which insurance companies I like and why I like them. They pay well. They're, the ones that I like are very, accepting. You can call them instead of calling the doctor's office if your doctor's office happens to be terrible at coding properly. You can call the insurance company and say, "Hey, it's actually this code.

Thank you." they pay quickly to the doctor's office. They respond quickly. You're getting somebody who sounds very, Doesn't sound the best, but you're getting somebody who understands English when you call them. Is, is the nicest way that I can try and come up with that. Sorry. I, like I said, I used to be medical billing coding, and I had to do a lot of those phone calls.

Probably why I still don't like the phone. Anyway, not every plan is the same, and my husband understood that, so he was given one plan that was really good, an insurance company that was really good, and one that was not. So this goes in with this question:

How should we actually compare two health insurance plans?

Is choosing the lowest monthly premium sometimes more expensive in the long run? As you can tell, it's a leading question.

I was gonna say when I, y- I read this question, I was like, "Oh, we, someone is familiar with how this can go sometimes." Yeah. So yeah, I think, we're always looking at how do people make this decision?

Because when we talk to people who are in the process of making a health insur- insurance decision, it's really confusing. There's a lot of moving pieces, and so often people kind of use these, tricks or things to, make a decision easily or more quickly. And so one of them that we definitely know folks say, "Hey, this is something that has come up for me when I'm making this decision," is they look at it and say, "Okay, this is the cheapest premium, so this is the one I'm going with."

And I should say I get that. I totally understand why, because you look at it and go, "Okay, this is coming out of my paycheck," or, "This is something I... It's another bill I've gotta pay." And so we look at it and go, "Well, I want my bills to be as low as possible, right? And so this must be the best option.

This must be the thing that is gonna work the best for me." When we talk in our classes about making the health insurance decision, we... The reason the program is called Smart Choice, 'cause we talk about making a smart choice when it comes to your insurance, because it's different for each person. So when we're looking at it, the goal is to identify your needs and then look at the features of the plan and figure out which one is gonna be the best fit for your needs.

Now, it sounds easy when I say it like that, but your needs can be a lot of different things. So some of the things you're talking about are, customer service needs. we evaluate- Other companies, like when I'm deciding who I wanna bank with, one of the factors that I'm gonna consider is, how many ATMs do they have?

How easy is it to get ahold of their customer service people? when I have a problem, are they helpful? I might go on Better Business Bureau and see what their rankings look like. When people have a problem, are they responsive? Do they get back to people quickly? Health insurance companies, it's, it's very similar, where we're making a decision about how we want our health insurance to work, but also who we're gonna work with for that process, and that can be very different between different companies, between different plans.

And so when we... I actually have one of our books behind me When we teach this in our class, what we encourage people to do is start by thinking about, okay, what are the health needs that you have? And so going through and thinking about, is it just me? Is it me and a partner? Is it me and a child? And, wh- wh- what doctors do we see, how often, those kinds of things.

And that's gonna tell you a little bit about, is this something that you're gonna use fairly frequently. When I was growing up, we always used to joke that, between my brother and sister and I, someone was going to the emergency room. W- it wasn't anyone's fault but, someone was going to the emergency room once a year.

And so we needed a plan that was gonna work well for that. So you start by thinking about, okay, when are the situations that this is gonna come up? What are the needs that I have that this needs to cover? and then you can start by think, start thinking about, okay, things like some plans require referrals and some plans don't.

Well, if I need a referral, that means that I need to see my primary care doctor before I see a specialist. They need to sign off on it, and then I see the specialist. If I have really limited ability to take time off of work, that means that if I'm seeing a specialist, I now have to make two appointments, and usually they're gonna be kind of spread out.

So I need the- And the referral needs

to be within three months of being seen, correct? Is that still

the- It's, it depends on the... Some of the insurance companies have their own guidelines for that c- but yeah, usually they don't want it to be like, and, and a year and a half later, here I am going for the appointment.

Yeah. and so thinking about things okay, given my work situation or my childcare responsibilities or things like that, is that gonna work well for me, that I need to get a referral for each time? other things about how the plan networks work, and I think we're gonna talk about that a little more later on.

But some of these features of the plan, so there's the cost side in terms of those numbers that we were just talking about, and then there's also the how easy is it actually to use side. And we wanna think about both of those things when we're making the decision. You mentioned about links in the description.

I'll make sure to share a link to this, book, but it's a resource that we've put t- together for people to try to do a fairly simple question and answer, walking people through this process. So it has places where you can say, "Okay, this is the co-insurance split. These are the co-pay amounts. Does it require referrals?

What does the network look like?" So it kind of helps you go through the process of pulling together all of that really important information and having it in one place. I always tell people, "Okay, I know this is maybe not gonna be the thing that you are, most excitedly looking forward to, but it really matters."

When the time comes and you're trying to address some of this stuff or you're trying to schedule a doctor's appointment or get a bill paid or whatever it might be- You want to have taken the time to understand and to make the best decision for yourself. So I- I'm right with you that this is maybe not anyone's favorite way to spend a Saturday, but I'm gonna strongly encourage folks that it really helps make sure that you understand the plan and can use it when the time comes

And really across the board, not every insurance company is the same.

And I will... I'm trying so hard not to name drop my favorites and versus-

I know. Yeah. And I should say, as a representative for University of Maryland Extension, when we teach our classes, we do, very broad generic examples. We don't, call out particular companies or anything like that.

But it's not a bad idea to look up the names of insurance companies that you're considering and just look at things are they having trouble getting a contract in place for some of the major healthcare providers in your area? Have there been issues with it in the past? Have they had trouble negotiating with doctors that you see?

'Cause that might be an indication that at some point in the future they're gonna keep having those problems. And one of the issues that we are starting to see is plans that change their network midyear. it used to be that those changes would really only happen in between plan years, so you'd have your open enrollment to make changes if you needed to.

I'm not saying this is super common, but we are starting to see more issues around- That just happened

last year, and I'm sure you've heard a lot about that specific company, and that's part of the reason why my husband switched jobs.

And, and it was a big- And I have a

lot of emotions behind it still for me, because thankfully we weren't affected, but there were so many of my husband's coworkers, and my husband works for a large company, that were not able to go to these Johns Hopkins doctors.

And if you're going to a Johns Hopkins doctor, you have something chronic. Like, I have so many emotions about this because it is so wrong, wrong, wrong what they did. And- And almost too illegal, if you're asking my opinion. Not that you did, but you have it anyway.

Well, and on the education side of things, one of the things that we're trying to do is make sure folks understand this should be part of, especially when, one of the things we think about are the providers that are available in different areas.

And we teach this program in Maryland, but we also teach it, we have trained educators who teach it in other parts of the country as well. and so, you might have a community where if this is the health insurance plan that I have and it, it isn't able to s- succeed in signing a contract with this group of providers, it might really limit my options for finding a provider that works for me in the community.

and so that can be really tricky for folks to kind of wrap their head around when they're making the decision, when they're going through the decision-making process. And so we try to really, in the book as we're walking people through this, make it very clear that the network of folks who the insurance plan contracts with- Has so much to do with who you're then able to see and how much you pay for those services.

It's really important to understand not just what the network is currently, but what, if anything, has gone on with the network in the past where you should kind of have your antenna up for changes that might happen in the future. especially if you are seeking specialized care or something like that, where a- an interruption in seeing a specialist is gonna be a really huge problem.

Yeah.

Yeah.

Okay. Yeah. This totally goes with the next question 'cause we're already diving in there.

Yeah.

So how do networks work, and what should we check before seeing a doctor, specialist, hospital, therapist, lab, or imaging center? And what mistakes commonly lead to unexpected out- out-of-network costs?

And maybe let's add to this, when should we fight it and when should we not?

Very good questions. So as we're talking about, one of the main sort of determining factors for how the plan is gonna work is who's considered in-network and who's considered out-of-network. So when we talk about these networks, we're basically talking about, okay, I always explain this in my classes 'cause it's such a confusing thing for folks.

The types of medical services that we might receive, the prices can change pretty significantly across the system. And so it's really difficult for both the health insurance company who is figuring out how much things are gonna cost and how much they need to set aside with premiums and that kind of thing, and then the medical providers as well.

So there's kind of multiple budgets going on here, and if you've ever run a household budget and, you say, "Well, I don't know how much that bill is gonna cost me," that's a big concern for your budget. You've gotta set aside wiggle room. If I know how much it's gonna be, that is much easier for planning purposes.

And so these networks happen when the providers and the health insurance companies sort of sit down and say, "Okay, this is how much all of these different services are gonna cost." And they do some back and forth. There's some negotiating and things that happen, and then eventually they get to a point where they say, "Okay, we agree.

We agree that a primary care checkup is this much. We agree..." So they have a... And I'm not in the room when these kinds of things happen, and I'm doing a very, I'm, I'm doing a huge overview of, of what goes on here. There's a lot more details. But essentially- It, it

depends on if they're a hospital versus a doctor's office, where a doctor's office says yes or no.

They don't get to negotiate. Right. I used to help do some of that part.

Yeah. So I'm, I am glossing over things a bit here, but essentially what we're getting at is they eventually reach an agreement and say, "Okay, these are the set costs." And so if they have an agreement in place, then that's gonna be an in-network provider.

And if they, for whatever reason, either don't pursue one or can't get one or different things happen, then those folks are gonna be out-of-network. And typically, the way that it works is that you are going to, for the most part, see in-network providers. For some plans- There is no coverage for going out of network unless it's an emergency.

For some plans, it's just more expensive to go out of network. and so usually we see things and then we get into acronyms, a PPO, a preferred provider organization plan, will have some coverage for out of network services. It'll just be more expensive, co-insurance rates increase, that kind of thing.

with something like maybe an HMO, a health maintenance organization, then we're gonna see in all... For the most part with those plans, there's zero coverage for going out of network. and so you're paying everything out of pocket. So that plan is really critical for knowing what services you're gonna be able to access and what providers you're gonna be able to access.

now, we mentioned a pretty major caveat to that, which is that for emergency services, you can go out of network. No one is expecting you to be mid-crisis and calling around to see who's in network for XYZ service. So, for emergency things, you can see anyone. For other, so we're talking more urgent care, primary care services, specialists that...

usually things that are planned a little bit further in advance, that's where we wanna make sure we're focusing on staying in network. And when we talk to the offices about it, we... The question you wanna ask is, are you an in-network provider for my insurance plan? Not, are you covered? Not, do you take XYZ insurance?

 I can take any insurance. The question is, are you an in-network provider? And you can ask that question at the provider's office. You can call them ahead of time, ask them when you go, or you can ask the insurance company. and they should be able to- I've

found it's-

Yeah ... more

accurate if you check on your insurance website than the other way around, 'cause I've had doctor's offices that say yes, and then they bill you and say, "No, never mind."

Actually, never mind. Yeah. Yeah. That is

extremely frustrating. It's more accurate on the insurance side than it is at the doctor's office level-

Yeah ...

urgent care level. Just giving you that little tip. And

if you're, if you're worried about it, you can always, let's say I make an appointment with XYZ specialist.

They say, "Oh yeah, we're in network." I can always call my insurance company and say, "Hey, I have an appointment scheduled with this person for this reason. I just wanna make sure that it's gonna be in network and that it's gonna be covered." Totally allowed to ask those questions ahead of time. The other question you asked is about, okay, when is it a, when is it a good idea to maybe, push back against some...

 wha- when are we maybe having some things that we need to address? I think one of the main ones is- There are definitely times where something gets categorized as not an emergency, and reasonable people can maybe disagree about whether or not that was the case. And I kind of gave you this example, we were chatting earlier, but I think it's a good one.

So when I was in college, my then boyfriend, now husband, had a kidney stone, but we didn't know that that's what it was. and so he was having really bad stomach pain. at that point, especially with someone like a college-age kid, you're typically not thinking kidney stone right away. And based on where his stomach was hurting, mainly what they thought was that it might be his appendix.

So went to the emergency room. They, did all the tests to figure out what was going on. They were able to rule out that it was his appendix and figure out that it was a kidney stone. And it turns out kidney stones, despite being extremely painful, are often something you can kind of address, depending on the size, are something you can address at home.

And so the insurance company came back and said, "We're not gonna cover this because it wasn't an emergency and you went out of network." And what I don't want is for anyone to get a message like that and say to themselves, "Well, I guess, I guess that's it. I guess I'm responsible for this. I guess I shouldn't have gone to the emergency room."

No. So in that instance, what we did was file an appeal and say, "Hey, This was a very reasonable set of actions to take in this circumstance. It was very difficult to know it was an emergency or not without appropriate testing and things to happen. So they filed the appeal. They said, "Hey, the doctors in the emergency room also thought this might be an emergency, hence why the testing and everything happened."

and it wasn't until they got the results of all of that that they knew what it was and, and knew what to do. And so these, those are the times when I would definitely... Like, if you went out of network because it was an emergency and you're getting billed for it later on, know that that is something that can be up to interpretation a little bit or could be up to what documentation was submitted along with things, whether or not the records really clearly show, the progression of what happened, the opinions of the medical folks who were involved, all those kinds of things.

So, definitely something we wanna pay attention to with the out-of-network stuff is that it can get categorized that way incorrectly, and that's something you as a consumer can appeal and have overturned.

Be your own advocate.

Yes.

And actually- Very much so ... if you really want to make sure it gets overturned, you are calling the hospital and you are calling the insurance company, both of them, to make sure they are both doing it right.

Yeah. That they both are expecting phone calls and documentation from each other, and that really gets the ball rolling properly instead of, kind of rolling in one direction and lopsided. But, and you can appeal multiple times. Sometimes you need to. Mm-hmm. The insurance adjuster's job, especially probably it feels like the ones that stay on longer and probably get raises are the ones that are denying claims.

So you are fighting against that. It's a whole, honestly it feels messed up system, but it is a system. So it's making sure that you are fighting it properly.

Yeah, I... This is something I alway- we have a program in our Smart Choice Smart Youth series that is all about, appeals. We call it disputes, resolving disputes, resolving conflicts.

and so we do an entire hour that is just on understanding that process, understanding what can go wrong, why, what your rights are as a consumer as far as getting some of those things, those decisions changed. Yeah, so you have an internal appeal and an external appeal. A pretty good majority of people when something gets denied never appeal it or ask for more information or, because so many folks, you get that thing in the mail that says, "Hey, this was denied.

Here's your bill," and they go-

The scare tactic. Yes "It's going to

collections

in this amount of time."

People get so nervous. And also I think some of the time, I've had people in classes say to me, "I pay my bills." When something c- it's a point of pride. It's something where they're if I'm responsible for something I'm gonna take care of it."

And I always tell folks, we have not determined who is responsible yet. It's also part of the reason why you get extra time when it comes to medical bills and things like that, because they know that there is this process, and there's time set aside for it. So don't let people make you feel rushed.

Don't let people make you feel like this decision has been made and it's set in stone. These are things that you can, you can file an appeal and get corrected. Now, I also really quickly wanna mention, so when we're talking about the appeals- That's gonna be for when the insurance company has made a decision and you don't agree with the decision that they've made.

So they might decide that it's not an emergency, it's not medically necessary, some of these different things. And then we can say, "Okay, I'm appealing that. I don't, I don't think that that was correct." There are also a whole other category of mistakes that can happen that appealing to the insurance company isn't gonna help very much, and that's when the mistake happened from the provider's end or maybe even our end.

 I had, one time I gave my insurance card, and I guess they just assumed that it was in my name but the insurance is in my husband's name. And so they ran it through with my name and then said, "You don't have insurance." And so, I had given them the insurance card that had the information on it, but it still, there was just a mistake that happened along the way.

And so, I can't appeal that 'cause that's not an, an error or, disagreement with the insurance. That's a clerical thing. That's something I've gotta resolve with maybe the provider's office or the billing office at the hospital, whoever, whoever that might be. so know that there's a couple of different avenues you have.

One is to fully challenge and say, "I, you, the you the insurance company have made a decision that I don't agree with." And when we're s- using the term appeal, that's what we're talking about. Why, the reason why we say disputes when we talk about it in our program is 'cause you can also dispute, whether or not coding was correct, whether or not something was billed.

I once went to a specialist and they billed for a new patient appointment twice on the same day. okay, well, obviously I didn't have two appointments on the same day at the same time for the same reason. and so, it doesn't help me to dispute that with my insurance company. They're only gonna pay for one of those.

I need the provider to remove the duplicate charge. so we have different mistakes that can definitely happen, and we wanna make sure that, again, if the appeal is the right thing, we wanna go that direction, but if it was some other mistake, we want to start kicking up a fuss and getting that addressed as quickly as we can too.

And honestly, most people in billing departments of any medical practice are willing to help you. Yeah. So that would be a great place to start rather than waiting on hold forever with the insurance company.

100%. Yeah, and the other thing that we're starting to see a little bit more often is providers' offices who are working with a third-party billing company.

and so if you are ever unsure or if you're getting a bill and it seems incorrect but the provider is maybe not super helpful, know that you might need to look for some additional folks who are involved in the process. I had to do this once with... I had to reach out to the third-party billing company to get them to correct something on their end.

The doctor's office had fixed it on their end, they just kept sending the bill. and the other thing too, in Maryland, we have something called the Health Education and Advocacy Unit through the Eternal- Attorney General's office, and they help with these kinds of things. So, more things for me to share in the resources with everyone afterwards.

But, especially for things that it's not appropriate for them to go through the appeals process 'cause they're not a health insurance decision, but it's still a mistake, and it's still someone who is, sometimes it's really hard to get people on the phone, or it's really hard to get them to call you back about some of these things.

So if you're running into some of those issues where it's more with maybe a third-party billing company or something along those lines, there are still resources, there are still folks who can help you navigate that process too

That is so helpful. So I just wanna reiterate a few things, and then we'll let you go.

She's gonna answer some questions in the newsletter, to get it further. and then you'll have the resources. Like I said, please share this away. But really think about your needs, and if you have a family, your family needs, and the location of your closest hospital and who they're in network with.

Think about your lifestyle, and then think about a little bit of that contingency planning like Carrie's mom did. Somebody's gonna end up in the hospital this year. Let's make sure we're good. So for me, when it was comparing between these two insurance companies a couple years ago, my husband knew which choice I was going to make, and he agreed with me, 'cause he heard how much I complained about this other insurance company that was an option.

And they are one of the insurance comp- They are so insulated you can only see their doctors within this, but because of that, they have amazing research that comes out. However, I'm not willing to travel an hour away to see doctors with my four kids. No, thank you . And they don't pay very well in general to their providers.

Yeah. another thing to think about is... And so many people are confused about this. This has been around for a long time, so you might have a little bit of an idea. When you go for a physical, usually it's not, you're not paying anything out of pocket unless you're doing any additional testing or unless you mention anything outside of the physical that makes that doctor's appointment go longer or they're discussing something else.

And typically, a doctor will, the second you mention something else, add in another code to make it just a little bit outside of a physical, because they are taking more time and attention with you. So just something to think about. And something more to think about, you have insurance more than likely.

Use it. Take care of yourself. This is a huge part of wellness. This is a huge part of making sure you live a long, healthy, happy life

Yeah.

There's

my soapbox. If you don't mind-

Go ...

I wanna jump in on that really quick and say people always, one of the things, so when we're going through in the class, right, and we talk about cost of insurance and all this different kind of stuff, and they're "What do I get for my premium?"

 you're saying, "Okay, this is how much I spend on my premium, and then there's all these other costs." But, do I get anything just because I'm a member? Yes. You get preventive services. So when we, talk about things that are included in the premium that you get typically for no out-of-pocket cost, those are your preventive services, your checkups, your screenings.

Those are the things that help catch problems early and help you intervene at a level when you're more likely to be able to really have a good outcome. and that doesn't happen in every single case, but in- we know across the research that taking advantage of the preventive services that are available to you helps you stay healthier, at every phase in life.

So that, it, I'm gonna jump on your soapbox with you and say please look into the preventive and wellness services that are available in your plan. If you... I always tell people, it's like if I found out my gym membership included, access to a sauna I'd never seen before, I'd be "Well, I'm, I'm at least gonna see what's in there because I'm paying for it."

So know what things you're paying for by being a member in your plan and, and if it's appropriate, try to take advantage of those things. talk to your doctor about it. Figure out a plan that works for you. Figure out which services are right. But ask about the preventive services and what kinds of things you can do there.

And if you do feel a little bit more stingy with your money, and this is, a pro tip here, if you're getting close to your out-of-pocket maximum, schedule in all of your appointments possible before your plan turns over for the year. that is when if you need any kind of surgery, anything, plan it right then.

Yeah.

and if you have HSA, health savings

Account ...

account. Like- Yeah ... plan. No. If you have an HSA, I prefer that one to FSA, which is federal. So HSA rolls over with you. Think of this as, your, IRA plan, but it's medical. You can take this-

Yeah ...

 put as much money into that as possible. The, it's another, really great retirement plan right there.

FSA- And

like the 401, you don't have to pay taxes on the money. Exactly. So it lowers your taxable income, and you're setting aside tax-free money that you get to use for medical expenses in the future. So if you're eligible for an HSA, look into it. It could really save you on medical costs in the future.

And if you have a choice between the two, do HSA. FSA is use it or lose it within the year. HSA rolls over, so that's why- Yeah ... I like HSA better. but either way, if HSA, sorry, if FSA is the only option you have, take it because it's Free, using quotes, money because it's untaxed. So you're getting- Yeah

part of that free portion, but it's another way to help you stretch out your dollars for taking care of yourself, and you can use it towards Band-Aids and towards allergy pills. Like, it's not just for the doctor's office. Yeah. And they have a list of everything and you can use it on. I have not had an FIC- F-S-A plan in 12 years, so I can't even tell you off the top of my head all the things that it can cover, that you can pay for.

But I remember I did not make the most of everything that was on the list, but I used it towards my husband's, Lasik. So I more than- Yeah ... maxed out my money that year, but I didn't do, the Band-Aids and, the... I think you could get sunglasses that year and, other things. But look at the list and make the most of your money and your time with all of this.

Go ahead, Kerry. What were you saying?

Yeah. I was just gonna say if you're curious about it, so the HSAs and the F- FSAs are, the rules for them are set by the IRS. There's a publication I can share that goes through all the details, but I'll also share, so our team that teaches the Smart Choice Smart Use program, we have a list of resources, and one of them is a document that explains the differences between an FSA and an HSA.

I will make sure we link to that. Thank you. but if you're not, if you don't wanna go quite down all of the, reading our fact sheets and that kind of thing, the next time you're in a CVS or a Walgreens or a pharmacy, they'll often have tags that say, FSA, HSA eligible. And so at least that gives you some idea of the kinds of things that you could purchase that you could use these FSA, HSA dollars for.

and so that, it, gives you maybe a starting point of looking into, oh, this, whatever it is that I might buy, Band-Aids like you were saying, or over-the-counter, Tylenol, something like that, I don't have to pay t- income tax on the money that I'm using for that. Again- All about getting the services we need at a price we can afford, and if that lets, if there's an opportunity at least for me to save some money on that, I'm trying to do that.

Yeah, make the most of it. Make the most of thinking about planning out your year ahead of time of, okay, my deductible will be used up here, so I'm putting in all of my appointments in here to get to my out-of-pocket max. Just think about how you can stretch your dollars as well as your time. So your time being do I want PPO or HMO?

So there's really, with everything in life, that time versus money. Really think about that for your family. And honestly save this episode because you're gonna wanna go back to this again. But go through, if you really need the help, go through the Smart Choices book, and if you go through it in detail, you probably won't need to spend that much time and attention the next time through even if you're looking at a different plan because you'll have done enough of the work mentally that you already have an idea of what to do next time.

And I love thinking about that. If I slow down and I really think things through, then I don't need to slow down every time for something similar.

Yes, absolutely. And if, save this like she said, come back to it. but if you need more information at some point in the future, our team teaches classes on this topic regularly.

so we do online classes, we do out in the community, the Smart Choice Smart Use program. We have nine different topics that we cover that relating to health insurance. so please feel free, reach out to us, let us know that you're interested in a class. We will get you signed up for one. but like we talked about, if- we could talk for hours and not cover all the things that there is to know about health insurance.

so if you are stuck, if you're confused, please know that we're here. I'm here as a service through University of Maryland Extension. What I do is making sure that information is available to people in the community when they need it. And so I always tell folks, my contact information is not a secret.

Send me an email, reach out to us, and we're gonna do everything we can to make sure that you get your question answered and that you get evidence-based information that you can actually use to do what it is you're trying to do. So please keep us in mind as a resource. We're happy to be there for folks in the community to help navigate this process that can be so confusing.

Yes. Thank you. And then I'm gonna ask you a question that you are going to get to answer in the newsletter. I just had a moment. There's my questions. Okay.

When we receive an explanation of benefits, what should we actually be looking at? How can we tell the difference between what was billed, what insurance negotiated, and what insurance paid, and what we truly owe? Especially because the explanation of benefits can look so different from each bill from each different medical provider, and that can be the hardest thing is reading how all the bills are set up differently.

Yeah. So

that right there needs to be in the newsletter 'cause there's so much there, and we might need some visuals. So hop on over to my newsletter if you're not already. you'll find it in the show description as well, because we want to continue this conversation and have this be a little more top of mind and not be so social media that you can't find it again.

This will be sitting in your inbox. You can save it. You can search for it within your inbox and find it again when you need it. You can share it with other people when you find out they're struggling with navigating insurance. So thank you for f- being on, Carrie. Thank you for listening, and thank you for sharing this episode.

Like I said, this is something that I would spend several months worth of phone calls and patients coming in to ask me for help, and this was me being one lowly medical biller and coder in one office, where this is something Carrie does for a living. Very different from my medical billing and coding, and she educates people on.

So this is why I asked Carrie to be here, plus my information is outdated. So thank you for this. Thank you for being on, and when this gets updated again, I will definitely have... When things change again, I will have Carrie back on to give us updated information.

Thank you so much for having me. This was a great time.

I really enjoyed getting to talk with you about it. And yeah, I look forward to coming back and talking about all the things that'll definitely change along the way.

Well, thank you.

Thank you.

Thank you so much for joining our discussion. If you enjoyed this, please subscribe. Most of all, share the love with others. Please share this episode so that we can help other people really recalibrate every aspect of their lives so they can be the best version of themselves, and I will see you in the next episode.

I want to have my quick disclaimer here that this is not a one-size-fits-all. If you want one-on-one coaching, let's talk, and we will make sure what wellness means to you is really put into your life, put into practice. I am using my undergrad in applied health and my life coaching experience to bring this podcast to you