With the Affordable Care Act in full swing, many consumers are surprised by the changes in coverage hidden in the fine print or couched in terms that are confusing. There are a lot of things to consider when choosing a policy. Even if you are covered, getting reimbursed can be challenging. Here are a few things to consider and some tips to get the most out of your coverage.


In order to pay for more preventive services and to comply with the regulations, more and more companies are coping by shifting costs to employees and consumers. When choosing a policy and when choosing providers, you must understand your coverage. Here are some definitions from Healthcare.gov. I have added questions to ask.

-Type of coverage – HMO, EPO, PPO, etc determines if you can use in or out of network providers, if you need a referral for specialists. Determine if your providers are in the plan and how much flexibility you want or need. Don’t go by cost alone as you may find yourself in a plan with none of the providers you want or need.
-Deductible- The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Ask which services do not go towards the deductible and which do. Only allowed services will go toward the deductible.
-Co pay -A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
-Co insurance – Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. Not only covered services require co insurance and it is payable only on the allowed amount.

Bill versus Explanation of Benefits (EOB)

The explaination of benefits is not the same as a bill. It is merely the charges are that are submitted to the insurance company by the service provider. This is your opportunity to alert the insurance company of any services that are an error or have not been delivered. This prevents fraud. Once you receive this, the insurance company will determine what the allowable charges are, what they will pay the provider and what you are responsible for based on your policy.

-Review your explanation of benefits carefully.
-Do not pay anything until you receive an actual bill directly from the provider.
-Once you get the bill, you can calculate if it is correct by comparing it to the EOB and what your plan specifications are regarding deductibles, co pays, co insurance and usual and customary charges.
-Only allowable charges at the usual and customary rate will be applied to the deductible and your rate of reimbursement will be based on the usual and customary fee, not the actual charge. For example: If your doctor charges $200 for a visit and the usual and customary rate is $100. Only $100 will go toward the deductible. If you have a co insurance that pays 70% you will receive $70 if you met the deductible.

Denied claims

Computers read forms now and although standardized and electronically submitted and scanned, mistakes are made and coverage may be denied.

-Ask why the claim or certain charges were denied.
-Appeal and resubmit with required documentation.
If it’s a coding issue, ask your insurance company to contact your doctor. Claims are now undergoing increased scrutiny. Insurance companies are now asking for your complete records and lab and radiology results to verify the medical necessity. Doctors are being audited. Insurance companies have more restrictions paying for tests that in the past were considered routine and fully covered without question.
-Verify where documents need to be sent and confirm that they were received.
The process takes time and there is margin for error every step of the way. Even though records were sent 2-3 times, companies claim they didn’t receive them or they were sent to the wrong place. Some companies have out of state addresses and there are different places to submit for drug, lab or professional services.
-Persistence is key. Many of my patients report that they get reimbursed after the third submission. So if at first you don’t receive, try, try again.

Laboratory, Radiology and Other Studies

Prior to the Affordable Care Act being ratified, the cost of delivering service has grown considerably. The implementation, training and maintenance of electronic records, systems and support as well as being compliant with regulations have added enormous costs. Tests that were paid for routinely are now being scrutinized or deemed experimental. Your insurance company may ask for a copy of your entire record and test results before paying for a claim.

-Ask if precertification is required.
-Determine if the studies will be applied to the deductible and if there is a difference if ordered by an in-network versus out-of-network provider.
-Use in-network laboratory or radiology facilities or you may be charged full retail price, which is considerably higher than in-network pricing.
-If you an out of network provider is ordering tests, you may be able to ask one of your in network providers to process the order to get better coverage.
-If you receive a large laboratory or radiology bill, call the company to negotiate a better rate. They are required to bill you 2-3 times and after that they may be willing to accept what the insurance covers and/or forgive certain charges.
-Remember the power of three. It often takes 3 attempts or 3 bills to get reimbursed or negotiate reductions.

Many insurance companies are now offering educational courses to help people understand their benefits. I recommend taking advantage of these since even if you are getting coverage with the same company, the policies, prices and coverage differ markedly from each other. It is no longer as simple as knowing your monthly payment, deductibles and or co pays. Get savvy and challenge your provider with persistence ad patience. However, if something is clearly not covered in your policy, you most likely will not have any recourse. Pick carefully up front as you will have to live with that choice for at least a year.

Author's Bio: 

Lorraine Maita, MD is a recognized and award winning physician and author-transforming people’s lives through preventive and anti aging medicine. She is a Diplomate of the American Academy of Anti Aging and Regenerative Medicine and Board Certified in Internal Medicine and has over 20 years experience in Preventive Health and Wellness, Internal, Occupational and Travel Medicine and Executive Health.

Dr. Maita served as Vice President and Chief Medical Officer at Prudential Financial, Medical Director on The Pfizer Health Leadership Team and Medical Director of North America for Johnson & Johnson Global Health Service and was an attending physician at St.Luke's/Roosevelt Hospital, Emergency Department and Executive Health Examiners in New York City. She is a consultant for companies wanting to develop or enhance their employee and occupational health and wellness programs and has a private practice in Short Hills, NJ. She is author of Vibrance for Life: How to Live Younger and Healthier.

Keep up with book signings and events at http://www.howtoliveyounger.com
Keep up with educational programs at http://www.vibranceforlife.com