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Thursday, March 8

A Few Tips for Navigating Today's Healthcare System

Okay, so in a previous life…I actually did high level contract negotiations with health insurance carriers.  I gave 12 years to health care administration and billing before I came home full-time to be with Zion.  Over the years, I have learned quite a bit of things that industry professionals do not want you to know.

I thought today that I would share a couple of things and perhaps save you and your family from learning some tough lessons the hard way.

1.  Know the lingo:  wording is everything when it comes to dealing with insurance companies as well as choosing doctors and dentists.

Do you see a difference between the following two statements?
Yes, we accept your insurance.
Yes, we participate with your insurance.

The difference could actually cost you hundreds of dollars.

When a physician's office tells you that they "accept your insurance" what they might actually be saying is that they will file a health insurance claim on your behalf, and that they will be glad to receive whatever payment your insurance pays as partial payment for their services.  In the end they will look at the amount your insurance pays and if it is a high enough payment usually cut you a "really good deal" on the balance, but either way you will still be surprised by unexpected fees.

When a medical practice tells you that they "participate with your insurance", they are saying that they have a contracted agreement with your insurance company, and accept a pre-negotiated rate for services they provide.  You may still owe a copay or coinsurance according to your family health insurance plan, but you won't be responsible for amounts outside your contract, or subject to inflated fees.

The bottom line:  always ask if they are a contracted participating provider with your specific plan.

2.  Know the loopholes:  when your health is at stake, making a little noise can work in your favor.  I personally worked for a group of the top neurosurgeons in New York and only a small handful participated with insurance.  However; I specialized in getting these physicians one-time contracts with insurance companies by pushing their specific techniques, specialization in a field and the failure of other surgeons to provide the same level of care.

The bottom line: it is your body, and you do have a choice on who provides your care, even when certain contracts restrict you to a network of providers.  Your fight will be in not giving in to the insurance company's attempts to persuade you to settle for something else.  I cannot in any way guarantee that a fight will always end in your favor, however; if it is important to you, you should fight until all options are exhausted, including all levels of appeals.

3.  Know that its a business:  the health care industry is a booming one.  The insurance company's are trying to make money, and so are the doctors.   Taking care of you is a means to an end.  Sad, yes, but very true.

The bottom line: Don't just behave like a patient, behave like a consumer.  Shop around.  Review recommendations online before wasting your time.  Don't go back to a place if you are treated poorly, the place is a dump or there are any red flags.  Get second opinions.  Sadly, some surgeons (I'd wager more than half)  really care more about the number of surgeries they perform than your personal surgery.  They may even try to do a more complex or invasive procedure than is needed.

I hope these tips help you, and feel free to send me an email if you have specific health care related questions.  I'll do my best to help you find your way.


  1. Becky JaneMarch 08, 2012

     Thanks for the tips.  I'm having to deal with my med ins right now!  First they said they would cover the total cost of a hoyer lift, but now after we've gotten the lift, they're saying that the policy has changed and they won't pay anything for it....grrrrrrrr

  2. Oh man, I hate it when that happens. Make sure going forward you always get the names of everyone you speak too, as well as any reference numbers or authorization numbers. Having records is crucial. Hope you get it worked out!


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