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Doctor Visit

"Planning" A Visit To The Doctor? Not as Crazy as You Might Think


New year, new benefits, new doctors, new rules. When it comes time to make that doctor appointment there are a few questions you need to ask before you head in for the visit. These inquiries will potentially save you a lot of time and money, so it’s worth your while.

Here is what you should know before you meet with your doctor as suggested by Consumer Report News in the article, "Your Guide to the New Health Insurance Rules."

1) In or Out of Network

All insurance plans vary, but in most cases you want to make sure that your doctor is covered under your plan’s network. To make matters less difficult, it’s best to call your doctor’s billing department to have them check your insurance plan prior to your appointment to avoid any unknown, or surprise, costs. On another note, don’t rely on the list of insurance companies itemized on the doctor’s website. It’s rare, but sometimes those lists are not completely updated.

2) Limitations and Exclusions

Essential health benefits are required by law to be included in all insurance plans; those are – physicians, hospitals, medication, maternity care, mental health care, medical tests, emergency care and rehabilitation.  However, in your Summary of Benefits and Coverage form you will find information on limitations and exclusions specific to your plan. Certain therapies, doctor recommendations or prescriptions may not be covered fully, or may not be covered at all.

3) Referrals

If you are in need of a specialist or if your doctor recommends you to have certain medical tests, you will need a referral from your primary-care doctor. If this step is skipped, your insurance plan may not cover these tests or different doctors.

4) Medical Test Coverage

If your doctor recommends a test, be sure to call your insurance company to make sure they agree that the test is medically necessary and to get the answers you need before the test is completed. Many times patients receive bills in the mail, months after participating in a medical test notifying the individual that they surprisingly owe thousands of dollars for the test. Be in contact with your doctor’s billing department and your insurance company, and keep a record of the information you receive.

5) Coverage of Medication

When you are prescribed a new medication, check to see what tier the drug falls under in your insurance plan. Each tier offers a different price cut-off and if the particular drug is categorized in a more expensive tier, you can ask your doctor about an alternative drug to lower your cost. Fortunately, there are usually many drug options that can replace a more expensive medication.

It’s always easier to handle insurance questions and concerns prior to your doctor appointment. If there are issues after the fact, it’s much more difficult to resolve the claim in a considerable amount of time because of paperwork and the need to contact several different parties in order to resolve the problem. If you are in doubt, you can always reference your benefits package, contact your HR department or reach out to your insurance provider. And in all cases, keep notes of the information you receive if you need to reference it later.

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