Simple Ways to Get the Healthcare You Need Without Overspending

by Julie Rains on 6 May 2013 4 comments

Getting the right healthcare services can be difficult under any circumstance.

In the past few years, my family members and I have had some relatively minor but pressing problems requiring medical attention. Making sure we had proper care at a reasonable cost was much more difficult than expected even though we have excellent insurance coverage. While stressful, these experiences improved my skills in navigating the healthcare system and, most importantly, advocating for myself. (See also: How to Find Free (or Cheap) Health Resources)

Here are lessons learned that I hope can save you time, money, and frustration.

Know Your Insurance Coverage

Reading your benefit guide is not the most exciting thing to do, but checking out what’s covered and what’s not is extremely useful. You don’t have to commit the handbook to memory, but you should read about coverage for preventive services, emergency services, and any other services that you are likely to need in the next year or so. This information can be beneficial when having a conversation with your physician or her staff about appointments, procedures, etc.

Don't Rely on Office Staff for Insurance Details

I have found that the physician’s office staff often provides misleading information about insurance coverage with advice ranging from ideal situations to worst-case scenarios. Certainly, they are trying to be helpful, but inaccurate guidance doesn’t facilitate getting better care or control spending.

For example, staff members often mention that insurance will not cover an annual physical unless an entire year has lapsed between the last one. While this may be true for many people, my insurance coverage allows such a visit once every calendar year. So, if I need to schedule a physical for May even though I came last year in June, I can still receive coverage for this earlier-than-usual appointment.

At the other extreme, physicians and their staff have told me that certain procedures are covered by insurance. Those healthcare professionals are unusually optimistic and often wrong. Sure, the treatment may be covered in the sense that a discount is available or charges are applied to a deductible (which could be $500 or $5,000, depending on your plan). At the very least, you need to know the out-of-pocket cost, which often means asking pointed questions of the billing staff and insurance company.

Choose What Works for You, Regardless of Coverage

In an ideal world, your healthcare provider recommends the most appropriate screening, diagnostic test, and treatment plan and your insurance covers the cost. And, much of the time, your needs and coverage match.

But sometimes, needs, recommendations, and coverage are out of sync. At these times, it’s helpful to consider the best course of action plus all of the costs involved in getting care.

For example, when I needed treatment for a running injury, my insurance plan covered physical therapy but not massage therapy. However, the cheaper approved therapy required numerous visits and had limited effectiveness whereas the more expensive, non-traditional therapy involved just a few visits. The non-covered treatment ended up being less costly in terms of money and time than the covered one.

In her article on getting medical care in pregnancy without traditional health insurance, Linsey Knerl mentions that you may be able to control costs associated with certain diagnostic tests. She recommends that you ask about the tests your physician may order routinely and make an informed decision on what tests to perform. This advice is sound whether you have insurance or not. Similarly, the Choosing Wisely website notes procedures that are often performed but may be unnecessary.

Remember that your time is valuable and even relatively small co-pays can add up to large expenses. Looking at the big picture and not simply coverage for an individual visit or procedure can help save money plus give you what you need.

Don’t Be Afraid to Enlist the Help of a Specialist

There seem to be many hurdles to accessing specialty care. The best and most cost-effective method is to receive a referral from your primary care physician. Ideally, your physician will recognize when specialty care is appropriate and refer you to the right type of doctor or therapist.

What makes the process difficult is that you often have to navigate various sets of rules:

  • Primary care physicians and their offices have internal procedures for referrals.
  • The insurance company has its guidelines about paying for visits to specialty providers.
  • Specialists often have their own sets of rules about referrals; some take physician-referred patients only, whereas others allow self-referrals.

While it’s true that your treatment may not be covered by your insurance company if you don't follow all the rules, you can still see a specialist without getting a referral.

Be careful to select the right type of specialist. In his book, "The Thrifty Patient: Vital Insider Tips for Saving Money and Staying Healthy," Davis Liu, M.D. references a study indicating that patients choose the wrong specialty area 60% of the time, which ends up costing more time and money than necessary. To prevent this kind of overspending, do your research and consult with your regular physician about the next step in the diagnosis or treatment of an illness, injury, or condition.

It's a good idea to investigate out-of-pocket costs before your appointment. But you may be pleasantly surprised to find that your insurance covers the visit and treatment whether you stick to everyone else's protocol or not.

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Use Your Insurance Company as a Resource

This approach may seem like aligning yourself with the enemy. But some insurance companies offer resources beneficial to navigating the healthcare system.

On my insurance company's website, there are physician performance ratings, updates on claims status, explanations of prior authorization requirements, details on wellness programs, and more. This online information has given me better understanding of administrative procedures and helped me to make decisions on healthcare services.

The customer service representatives have also been helpful by answering questions about coverage based on my circumstances, accelerating the process of getting a pre-authorization, and straightening out billing issues. They have provided clear direction and saved me time that I would have otherwise spent dealing with medical office staff.

Get the Right Physician and Practice for You

Finding the right doctor’s office and physician requires thoughtfulness about your own needs and research on credentials, availability, and more. But your selection can make getting what you need easy, especially if your style of communication meshes well with the physician and staff, or maddeningly difficult, if you don’t understand each other.

For example, the diagnosis of an injury may be delayed if your physician doesn't grasp the severity of your pain following an accident. Treatment and recovery may also take longer if warning signs of complications and follow-up procedures are not explained thoroughly. So finding someone who listens, knows how to ask you questions, and makes sure you understand next steps is essential.

Create a List of What's Important

Make a list of what's important to you. Mine includes a commitment to personalizing care, the ability to make clear and accurate recommendations with a bias toward non-drug interventions, and a professional, knowledgeable staff. Whatever you value, look for a physician that matches your preferences.

Online review sites, such as Healthgrades.com, and recommendations from friends can be helpful but may not give you the full picture. The best reviews are not numerical rankings only but narratives that offer insight into the physician’s philosophy and strengths.

Objective measures are also useful. Start by checking for disciplinary actions on your state’s medical board website.

Continue by researching clinical quality. My insurance company's website provides information relating to physician performance on certain measures relating to screening recommendations. Interestingly, some popular physicians perform below expectations according to these ratings, illustrating that friendliness doesn’t necessarily equate to appropriateness of care. Ideally, find someone who has excellent clinical capabilities and treats patients well.

Whether you have a high-deductible health plan or a more traditional one, getting what you need without overspending requires effort. What I have discovered is that engaging healthcare professionals who are interested in addressing concerns and solving problems (rather than chasing insurance coverage) has been most beneficial to my family and me.

What are you doing to make the most of your health care dollar?

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Guest's picture

Good post. I especially like the tips related to using your insurance company as a resource and creating a list of what's important to you when it comes to your health care.

I maintain a document that lists the history of my surgeries, medication, vitamins, emergency contacts, etc. This comes in handy when I go to a new doctor. I never struggle when filling out their paperwork because I have all the information on my sheet and simply put "see attached" in the applicable sections.

Ree ~ I post at EscapingDodge.com

Julie Rains's picture

Great idea to have your own list -- I have a file but should create my own document as you have. Seth Godin wrote about such a form a while back and this post contains a link to a template:

http://sethgodin.typepad.com/seths_blog/2013/02/the-simple-form-that-cou...

Thanks for your comment!

Guest's picture

Good list. If your employer offers a health flexible spending account, you may be able to do some of your out-of-pocket spending tax free even if you don't have an HSA.

Julie Rains's picture

Thanks for the mention of the FSA -- I should have thought of that! You have to be more careful about how much you set aside (b/c of the use it or lose it rule) but it's a good way to save money through the tax break.