How to Get Your Treatments Covered by Insurance



The average American pays about $1,400 out of pocket on medical expenses every year, even with health insurance. But chances are that savvy moves could have trimmed some of those direct costs.

Here are some expert strategies to maximize your insurance coverage.

Watch Your Timing

If you need elective surgery — any procedure that isn’t medically urgent — you may be able to limit the hit on your pocketbook by scheduling it strategically.

One simple way to do it is to book your surgery early in the year to meet your annual deductible, says Lauren Jahnke, a health care consultant in Austin, TX, and author of Decoding Health Insurance and the Alternatives: Options, Issues, and Tips for Saving Money.

A deductible is the amount you must pay first before your insurance typically kicks in. That can be $2,000 or more per person. Once you’ve met that, you won’t be hit with any deductibles for medical treatments you need later in the year. But if your elective surgery is in December, for example, you may have already reached or exceeded your deductibles. That risks leaving money on the table if you could have gotten full credit for the deductible for your elective surgery in another year.

When it makes sense to schedule an elective procedure later in the year: This timing trick works if you need, say, both of your knees replaced. See if you can schedule the joint replacement surgeries for the same calendar year. That way, you avoid paying the deductible twice in 2 different years.

Get Preauthorized

This is a common requirement with expensive treatments. Preauthorization comes from your insurance company, and you need it before you start a treatment or therapy or have your operation. Preauthorization is an insurer’s acknowledgment that your treatment is medically necessary. Contact both your doctor and health plan to check if you need one. If so, your insurer may reject payment for treatments without prior approval.

Turn Your Doctor Into an Ally

Want to try an experimental treatment? It won’t be easy to get coverage because insurers tend to deny payment for treatments that are not well-established. “You have to lobby the insurance company,” Jahnke says. Don’t be shy about asking your doctor to make the medical case for the treatment.

If you have migraine and have gotten little relief from your current medications, your doctor may prescribe newer, more expensive drugs. Be sure your doctor’s office sends your medication history to your insurer first. It may require you to try less costly drugs before you can switch.

Stay in Your Network

If your doctor has recommended an elective procedure, consider scheduling it for 2022. Why? Because beginning Jan. 1, a new law will take effect giving you some protection against so-called surprise billing. But in 2021, if, for example, you have surgery and the anesthesiologist is out of network, your insurer may pay little or none of the anesthesiology fees, and you could end up owing thousands of dollars.

But even after the new law takes effect, you’ll need to keep an eye out and ask questions about all the professionals who may participate in your care. “The surprise billing law was written pretty tightly, but I think it may take a while for hospitals and doctors to get used to it and for insurers to correctly flag what’s protected under the law,” Pollitz says.

Know What’s Free

COVID-19 vaccinations are 100% covered, even if you don’t have insurance and even if the pharmacy or the doctor isn’t in your network. Tests to check if you have COVID-19 are usually free but not always. Public health clinics and participating pharmacies, including Walgreens, Rite Aid, and CVS, offer tests at no cost.

Appeal if Your Insurer Refuses to Pay

You have the right to challenge any claim that’s denied. You can ask your insurance company to review whether its decision was fair.

You also can ask a third party to rule on it. This is called an external review. This review is free if your health plan follows a federal external review process. There may be a fee if the review uses an independent group or a state external review process, but it can’t be more than $25.

Another option is to call your state’s Consumer Assistance Program. They’re often staffed with insurance experts and attorneys. These advocates may even make calls for you or help you file a claims appeal.


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