Most of us have fond memories of dancing the Hokey Pokey as children.  Who would have known it would come in so handy as adults?

health care advocates can help you learn the Health Insurance Hokey Pokey

Health Care Advocates can teach us how to do the Health Insurance Hokey Pokey

The manner by which insurance companies create healthcare provider networks and how healthcare providers decide to participate in or opt out of those networks is nothing short of a wildly complex version of the Hokey Pokey.  Once you go out of our preferred network, you can find yourself at serious fiscal risk.  Yet, if you understand the basics of in/out of network coverage and potential pitfalls, you’ll be far less likely to be caught pokeying when we should be hokeying (or vice versa).

Patients with PPO policies (and insurers’ latest creative variation on the theme called EPOs – a hybrid between an HMO and PPO) have to avoid accidental missteps caused by ever-changing networks.  It’s often difficult (if not impossible) to find the correct provider network listings for a particular policy on an insurance provider’s web site, and those listings are not always reliable.

Another major financial issue arises after patients receive care.  As reported in a recent New York Times article, (http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-network-but-the-doctors-are-not.html?smid=tw-share&_r=0), even patients who believe that they are using in-network providers can find themselves faced with thousands of dollars in out of network charges.  Patients may be unaware that someone involved in their care at the hospital, doctor’s office or even a laboratory the healthcare provider is using is out of network.  Seemingly faced with no other alternative, patients far too often pay the medical bills not covered by their insurance without question or negotiation in order to protect their credit ratings.

There are several steps you can take protect yourself and your family.  Here are a few tips:

    1. Before choosing a new PPO (or EPO) health insurance policy, call and speak with your healthcare providers.  Make certain the billing department of the hospital and your doctor’s office confirm that they are in the network of the specific plan you are considering.Even if you are staying with the same policy as the year prior, check to see that your doctors/hospitals are still in that policy’s network.  Networks often change, and you need to make certain you get to keep the healthcare providers you trust.
    2.  Call to your prospective or current insurer and ask their representative to confirm your providers are included.
    3. Prior to a non-emergency test/procedure, confirm with your healthcare provider(s) that:
      • All personnel involved in your care are included in your network
      • All labs or testing facilities are in-network
      • All tests/procedures to be performed are medically necessary
    4. For non-emergency procedures, negotiate pricing up front and ask for a detailed estimate.  Calling different providers in your areas for standard tests and procedures can save you a great deal of money.

Lastly, contact your insurance company prior to receiving care to make certain you have all pre-certifications and pre-approvals, if required, in place.

Our company recently developed a set written parameters for healthcare providers, called a Patient/Provider Agreement, for our clients’ use.  The document states that the providers will provide in-network, medically necessary care to our patients at fair market value prices.  It stipulates that healthcare providers commit to using in-network caregivers and testing facilities.  If in-network care is not possible, the patient must be made aware of it in writing.

Patients are often asked to sign our fiscal lives away when they complete intake forms at the hospital or doctor’s office.  “Blank check” clauses that hold patients financially responsible for “all costs associated with treatment that are not covered by insurance” are open ended and dangerous.  Even though providers may refuse to sign a patient/provider agreement, it still serves notice that the patient’s healthcare process is being carefully managed.  Patients deserve to be afforded the same financial protections as hospitals, doctors and other healthcare providers afford themselves.

Empowered, vigilant patients are savviest of consumers.  The best chance you have at financially surviving the dance is up to you.

Sarah O’Leary is founder and CEO of Exhale Healthcare Advocates (http://exhalehealth.com).  She and her colleagues can be reached via email at breathe@exhalehealth.com