3 tips to protect health care coverage

3 tips to protect health care coverage

When Anthony Ponzio of Chicago underwent a coronary artery bypass operation to treat blockages several years ago, he did so only after his insurance company, Blue Cross and Blue Shield of Illinois, authorized coverage. But, according to court records, after undergoing the more than $200,000 procedure, Ponzio received notification the insurer planned to rescind his coverage.

“Once they saw the bill, they said, ‘We made a mistake,’” says his attorney Alan Alop, director of the Consumer Practice Group for the Legal Assistance Foundation of Metropolitan Chicago. Blue Cross and Blue Shield of Illinois cited a pre-existing condition — high blood pressure — but Ponzio’s doctor argued against that claim, calling it a “deliberate and transparent distortion” to drop coverage, according to a lawsuit Ponzio filed in 2010 in Circuit Court of Cook County against Blue Cross and Blue Shield of Illinois.

The insurance company eventually reached a confidential settlement with Ponzio that precludes him from discussing details of the case, but court records show he’d been insured by BCBS since 1993. A spokeswoman for BCBS — which has mostly high ratings from Chicago Angie’s List members — declined comment, citing privacy laws.

Billing advocates say apparent coverage reversals happen all too often. They name two common scenarios: In the first, patients call an insurer to clarify if their plan covers a particular procedure or service and a rep confirms it does — often in error — but the insurer later denies the claim. “That happens quite a bit,” says benefits advocate and attorney Susan Loeb of Your Benefits Advocate in Chicago. “You can call three times, talk to three different reps and get three different answers.”

In the other scenario, the insurer rescinds an individual’s plan after authorizing coverage, alleging issues such as undisclosed pre-existing conditions. “A lot of people don’t have the money or time to fight cases like this,” says Sandra Washington, a patient advocate with Medi-Helpz in Chicago, who currently charges $100 an hour but will soon bill per project to help with medical billing issues.

A provision in the Affordable Care Act that took effect Sept. 23 requires health insurers and group health plans to summarize benefits in plain language consumers can understand. But given the complex nature of insurance, Loeb says it’s perfectly reasonable for planholders to call their insurer for clarification. “The question is, ‘To what extent can a patient rely on what the insurance company tells them?’” says Loeb, who charges clients on a sliding scale, with claims appeals starting at $125 an hour.Here’s three things that experts say you can do.

1. In addition to reading your plan, Washington says, get procedure codes from your doctor for services you wish to inquire about before calling your insurer.

2. Ask your provider’s billing office if all involved in care — including anesthesiologists, radiologists and labs — are in your plan’s network, experts say, and request cost estimates in writing.

3. Ask your insurer to confirm estimates, including how much you can expect to pay out of pocket. Jot down reps’ names, times and dates you talked, in case you need to appeal a claims decision later.

“I tell people all the time, try to get as much in writing as possible,” Washington says. “It’s probably something you’re going to need if they turn around and deny.”


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