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As a professional who works regularly with insurance companies, it’s apparent that many people are misinformed about their coverage. Customers are paying, often a lot of money, for a product they don’t fully understand. Typically, consumerism is a logical and social process: one inspects the product they are going to pay for, discover any and all lingering details that could sway the sale one way or the other, and then follow that up with a social analysis in the form of reading reviews and consumer reports. The same cannot be said for insurance.

There are exceptions to this rule and there are highly informed people who understand exactly what they are paying for. For the most part however, based on my own experience working with hundreds of patients with different insurance policies, people are left in the dark. This seems conveniently intentional on the part of insurance companies, keeping people misinformed by hiding under the veil of ignorance and confusion. This becomes their greatest asset because people will pay high premiums for bad benefits.

Even professionals who specifically deal with third-party reimbursement for their job are often left guessing. Poorly trained insurance representatives can present inaccurate info, or hide in ambiguity offering “recommendations” instead of requirements. This creates a swift domino-effect, promoting the spread of misinformation to the individuals on the receiving end: You. Suddenly, you could receive a hefty, unexpected bill in mail because the company you are paying did not make it a top priority to inform you or train their representatives.

Insurance companies are paying your healthcare professionals less.

This is undoubtedly true across-the-board, from your family physicians to your physical therapists. Insurance companies write-off massive amounts of the bill, which means your doctor is getting paid less for the same service. This is nothing new and the trend is not optimistic. Write-off amounts are increasing as time goes on, with more financial responsibility being placed onto you, the customer, with higher premiums and worse benefits. Sometimes the write-offs for certain plans are so abhorrent, healthcare providers opt out of their network. This is the case for our clinic and United Healthcare. UHC offers to pay too little and has awkward restrictions such as treatment time limited to less than an hour. Due to these restrictions, our clinic is essentially forced to be out of network, which results in less coverage for our patients with that policy.

This movement has created a rift, specifically within the outpatient physical therapy arena. Increasingly, clinics are offering competitive self-pay rates, that of which rivals insurance coverage, or lack thereof. Instead of paying $150 for each visit until one reaches their $4,000 deductible, only to be covered 50% (no, this is not an outrageous exaggeration), people now have the option to only pay $125 for each visit, covering everything.

Another appealing trend for the outpatient crowd are cash-based clinics who do not accept insurance whatsoever, completely cutting out the middleman and confusion. Obviously this isn’t a viable solution for everyone and many cannot afford to pay out-of-pocket. But considering how rampant poor benefits are running today, it is almost guaranteed that cash-based clinics will become very mainstream in the near future, especially among the healthier athletic population who do not regularly need to use health insurance and, as such, opted for cheaper premiums with less benefits.

What can you do?

At the end of the day, one’s healthcare, along with everything associated with it, is one’s own responsibility. Although there are clerical and healthcare professionals to help along the way, it is important to maintain one’s own sense of control. Rather than fully depending on someone else to tell you what your benefits are, consider calling your insurance company. Unsurprisingly, insurance companies are more receptive to people who are paying for their premiums, rather than businesses who are trying to get them to pay.

Above all else, seek education. Use google and understand the basic principles of insurance including copays, coinsurance, deductible, maximum out-of-pocket, and in-network vs out-of-network benefits. Call your insurance company and figure out exactly what your coverage is for each service. Nearly all plans hold different coverage policies for different disciplines and settings, meaning a regular doctor’s visit will not have the same coverage as urgent care, the ER, or physical therapy.

If you do have thorough knowledge about health insurance and are informed about what your benefits are, congratulations! You are one of the few. Pass on your knowledge.

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