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  1. Keep a record of any medical services and procedures you receive. In a notebook, keep track of doctor visits and any care received at the hospital or other medical facility. Note dates and types of service rendered (including lab work, tests, x-rays, therapy, etc.), where the service was provided, diagnoses made, medications prescribed and other specifics. Do the same for all covered family members. This information is vital for checking your EOBs (Explanation of Benefits) later on. Some plans also offer this information on a secure site. If you are an UnitedHealthcare customer you can find this information at myuhc.com. Print a copy if you change plans.
  2. Give health care providers your most recent health insurance card. When you receive a new health plan ID card from your insurance company, immediately replace your old card with the new one. To process your claims correctly and avoid payment delays, your doctor’s office and other providers need the most up-to-date ID card.
  3. Carefully review the EOBs (Explanation of Benefits) you receive from your insurance company. Processing medical claims is a complicated process, and mistakes can happen. Just as you double check your bank or credit card statements, review your EOBs closely for accuracy. Make sure the dates and services shown match your records. Call the number shown if you have questions or think there’s a problem. (See Learn More for helpful tips on reading and understanding EOBs.)
  4. Know how your health plan works. Your EOBs will make a lot more sense when you understand what your health plan covers and what you are responsible for paying. How much is your annual deductible? What is your coinsurance percentage? Does your plan require office visit co-pays? Are there precertification requirements? How is out-of-network care covered? What is the plan’s annual out-of-pocket limit? If you don’t understand these basics, contact your health plan customer service or member services department at the number shown on your ID card. For UnitedHealthcare customers you can call, 800-752-1816.
  5. Understand that some medical services - particularly tests - may involve "behind the scenes" doctors or facilities. When you have an MRI or lab work, your EOB may show charges from the facility that analyzed your lab work or the radiologist or pathologist who read your tests. If you aren’t sure about a charge, call the phone number on your EOB.
  6. Pay your doctor promptly for your share of the cost. Copayments are due at the time of visit. If you haven’t yet met your annual deductible, pay your provider as soon as the claim is processed and the network discount has been applied. In most cases you are responsible for 100% of the cost up to your deductible amount. Once you’ve met your deductible, wait for your medical plan to pay its share and then promptly pay the remaining balance for which you are responsible. If you can’t pay your share all at once, call your provider to work out a payment schedule.
  7. Save money by taking advantage of tax-free payment options. If your employer offers flexible spending accounts (FSAs) or health reimbursement accounts (HRAs), use these accounts to pay your share of health care costs. Both accounts are tax-free, helping you stretch your dollars further. Employees in "high-deductible medical plans" may qualify for health savings accounts (HSAs) - another tax-free way to pay your medical costs. (See the Learn More section for more on these accounts.)
  8. Select physicians and facilities in your plan’s network. The providers in your network have agreed to discount their charges and meet certain credentialing requirements. By staying in-network, you may significantly lower your costs. If you are a UnitedHealtcare customer use a physician designated as Tier 1 provider. This may reduce your out-of-pocket costs.  Using a Tier 1 physician also insures that you are seeing a physician who meets quality and efficiency standards set by UnitedHealhcare. Tip: Before receiving care, always check with your plan to make sure the provider is still in the network. Otherwise, you’ll probably pay a lot more - you may be be responsible for paying the full price plus any amounts that are above reasonable and customary limits.
  9. Get organized! Set up a filing system to keep track of EOBs, bills, receipts, lab results and other health care information. Since medical costs can represent a significant expense for many families, it makes good sense to keep track of this information.

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Health Plan Terms

Medical Terms Dictionary

Health Conditions

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How to Read your Explanation of Benefits

Different insurance companies use different forms, but all EOBs contain the same key information.

Start by checking the basics: information about the member (the primary person enrolled in the plan) and the patient (the person who received services). Have the claim number and your insurance card handy if you have to call with a question

Check the dates of the services you received. The provider is the person or facility that submitted the claim. The service code tells which service was provided. The codes are explained down in a different area. Note: What seems like a single service often involves more than one provider, especially X-rays and lab tests.

Now the dollars and cents: how your claim was processed. The charge is the amount billed by the provider. If a network discount applies, it will be shown here. Then you’ll see any other excluded amounts, which the plan does not pay. Excluded amounts could include your deductible, coinsurance or copayments, depending on your plan

Here’s an example of a network discount: The doctor charged $150 …. minus a $40 network discount… leaves $110 as the covered charge.

Then the EOB shows the benefits paid by the plan. The benefit is usually a percentage of the covered charge, like 80%. The insurance company sends the provider a payment for this amount. Most EOBs show an amount called the Estimated Member Responsibility. That’s the amount you owe the provider, after the plan benefits are credited to your account.

Be sure to read any notes, explanations and reason codes. These tell why a claim was denied and alert you to any actions you may need to take.

Medical Claim Process

It starts when you receive care. The doctor writes notes in your chart

Then, the doctor or office staff will take a routing slip full of service codes, and check off the codes of the services you received.

Medical claims are all about the codes. A billing person puts those codes into a claim form and sends it electronically to the insurance company or claims administrator. They’re the ones who figure out how much your plan will pay, based on those codes. Then they send you this EOB. Accuracy of the codes really matters.

For example, some plans pay a higher percentage for preventive care than for other types of care. So if you go in for a preventive checkup, but the exam is mistakenly coded as “problem-focused,” then the claim won’t be paid right. You could pay more than you have to. Tip: As a result of the Affordable Care Act many preventive services must be reimbursed at 100 percent by your insurance carrier -- another reason to make sure that preventive care is accurately coded.

There are thousands of codes, and someone could easily check the wrong one, or misread what someone else wrote. And if the claim is coded wrong, the benefits won’t be right.

FSA vs. HSA vs. HRA

As mentioned above, if your employer offers an FSA, HSA and/or HRA, you should consider opening an account and contributing to it.  You can contribute on a pre-tax basis to help you pay for out-of-pocket costs not paid for by your insurance company.  Below is a table showing the differences between these accounts and their benefits.

FSA (Flexible Spending Account) HSA (Health Spending Account) HRA (Health Reimbursement Account)
Who contributes to it? Employee Employee and/or employer Employer only
Who owns it? Employee Employee Employer
Is it portable if you leave your current employer? No Yes No
Does unused balance carry over after year-end? No Yes Possibly, at employer’s discretion; maximum limits may apply.
Is the account invested? No Yes, although a minimum balance may be required; the investment options available vary by financial institution. No
Are there any service or maintenance fees on the account? None to employee (employer pays). Yes. Typically the employer pays the fees as long as you are employed there. None to employee (employer pays).
What are the tax benefits? Contributions are tax-free, which reduces your taxable income. Contributions and earnings may be tax-free, which reduces your taxable income. Contributions are tax-free.
Can it be used for anything other than eligible health care expenses? No Yes, but if withdrawn for non-approved expenses, the money is subject to income taxes and possibly a 10% penalty. No

What Happens If You Go Out of Network

Some plans pay no benefits if you use a doctor or hospital outside the preferred provider network, while others pay reduced benefits for out-of-network care. The following is based on typical plans. Your plan may be different. To find out if a provider is in-network, call the number on your health plan ID card or visit the plan website.

If Your Plan Pays Reduced Benefits for Out-of-Network Care…

  • You’ll probably have to meet a separate deductible before benefits are payable for out-of-network care. There may be exceptions in a true medical emergency.
  • An out-of-network provider’s charges are almost always higher than in-network, since there is no discount arrangement.
  • Since out-of-network benefits paid by your plan are lower, you’ll pay a higher percentage of those already-higher charges. There may be exceptions in a true medical emergency.
  • In addition, you may have to pay any charges in excess of the usual and customary (U&C) or reasonable and customary (R&C) amount. These are the amounts your plan determines to be typical and/or acceptable, based on what providers in a given geographic area usually charge. Some providers charge more than the U&C or R&C amount, others charge less. If you go out-of-network and face excess charges, you may be able to negotiate with your provider to reduce your balance due.
  • Amounts you pay for out-of-network care usually don’t count toward your in-network deductible or out-of-pocket maximum.
  • Amounts you pay for out-of-network care can be reimbursed from an FSA (flexible spending account) or HSA (health savings account).
  • Some doctors who practice at in-network hospitals may be out-of-network providers. For example, the radiologist or pathologist may be independent of the hospital and bill you separately. Just because you are at an in-network facility doesn’t guarantee all doctors working there are in-network. If you charged higher, out-of-network rates, contact your benefits representative. In some cases - but not always - they may be able to negotiate on your behalf.
  • Even at an in-network office visit, the doctor may use an out-of-network lab. Ask your doctor which lab service he or she uses, so you can call your plan and find out whether it’s in-network. If it isn’t, ask your doctor if you can have a prescription for the needed lab tests, which you can then take to an in-network lab.

If Your Plan Pays No Benefits for Out-of-Network Care...

  • You are responsible for paying the full charge. There may be exceptions in a true medical emergency.
  • Amounts you pay for out-of-network care don’t count toward your deductible or out-of-pocket maximum.
  • Amounts you pay for out-of-network care can be reimbursed from an FSA (flexible spending account) or HSA (health savings account).

More Resources on other topics

Frequently Asked Questions about health insurance

Preparing for your doctor visit

Prices at Wisconsin hospitals

Health care quality ratings

Health risk assessment

Why are health care costs rising?

In simplest terms, spending on health care is the product of two factors: price and utilization.

  • Prices charged by hospitals, physicians, drug companies and other health care providers have risen dramatically – more than the cost of goods and services in general (inflation).
  • Utilization of health care services is up. Despite rising prices, demand for services remains high. More of us are using health care services more often, for more conditions – including some that were not even treated in the past.

Why are medical prices going up, and why are we using more care? Here’s where things get complicated. Experts differ in their conclusions about what – or who – is most to blame, but there’s widespread agreement that certain cost drivers are at work.

Key Cost Drivers

Americans’ lifestyle choices are partly to blame. Unhealthy eating, lack of exercise, smoking, not getting enough sleep, alcohol abuse all put us at higher risk for a host of costly illnesses including heart disease, diabetes, cancer, arthritis and more. Obesity rates in adults and children, while showing signs recently of leveling off, still remain high and suggest health care costs will
continue their upward climb. In 2011-2012 approximately 17% or 12.7 million children and teens in the U.S. were obese. Extra pounds put children at an increased risk of developing type 2 diabetes, high cholesterol, heart disease and other expensive health problems for their lifetime. (Source: Journal of the American Medical Association, February 26, 2014, Vol. 311, No. 8.)

Advances in medical technology have led to amazing breakthrough treatments. The research and development costs behind these new technologies must be recovered somewhere – typically through the general cost of medical goods and services. And we’re all paying the high price. Still, Americans want the latest treatment at their disposal, whether it means an expensive bone marrow transplant that may be yet unproven as treatment, or a heart bypass operation at age 85. Our society’s devotion to technological discoveries ensures that costs will continue to rise. No matter what employers do to manage costs, the impact of technology on spending will continue.

Prescription drug costs are rising even faster than medical care overall. Some of the most exciting – and most expensive – developments in medical care involve prescription drugs, specifically specialty drugs. Specialty drugs now account for approximately 20-25 percent of pharmacy spending and the cost of these drugs is expected to quadruple between 2012 and 2020.

Many claim that direct-to-consumer drug ads are prompting patients to request the newest (most expensive) brand-name drug, even when a generic or over-the-counter drug may work just as well. Another concern is that drug ads rarely mention the lifestyle changes or other, non-drug solutions, which are often just as important as drug therapy in improving outcomes. For example, a patient may resist when his physician insists on discussing a low-fat diet, stress management, or allergen avoidance rather than writing a prescription.

Whatever the reason, employees’ usage of prescription drugs, and the cost of those drugs, has significantly increased recent years and is expected to continue rising.

Did you know?

The U.S. and New Zealand are the only countries that allow direct-to-consumer drug advertising that includes product claims.

Source:Abel GA, Penson RT, Joffe S, et al. Direct-to-consumer advertising in oncology. Oncologist. 2006;11(2):217–226

An aging population needs more care. In 2010, there were 40.3 million people aged 65 and older, 12 times the number in 1900. By the year 2030, the older population will number approximately 73 million.
Source: U.S. Census Bureau, report issue June 2014.

What’s the significance of these statistics? Often, as people age, health problems increase. There are more people getting treatment for the types of one-time problems that accompany middle age, such as gallbladder surgery. Just as important, more people now need ongoing care for the types of chronic conditions that may develop with age, such as back problems or adult-onset diabetes. Often, that treatment includes expensive prescription drugs.

The costs associated with older people will not diminish anytime soon. Today’s youngest Baby Boomers will still be in the workforce 15 years from now. As a demographic group, their health costs will balloon as they age and use medicine to live long, active lives. Advances in health care are part of the reason we’re living longer, which in turn is driving our national health care spending even higher.

Did you know?

Approximately one-third of health care treatments, costing $750 billion annually, are unnecessary. Millions of patients receive unnecessary treatments each year, leading to complications, reduced productivity, and significantly higher costs.

Source: Institute of Medicine Report, September 2012.

Consolidation in the health care marketplace means less competition. That gives employers less leverage to negotiate favorable pricing. As a result of consolidation, many health care systems have transitioned services from a not-for-profit to for-profit status, adding the cost of “profit” to medical charges. In addition, there continues to be a great deal of opportunity to streamline the wide range of administrative processes used today in order to eliminate waste from the system.

Governmental factors also play a role in health care cost inflation. Hospitals and doctors receive limited reimbursement from Medicare and Medicaid for patients in those systems. To keep operating at a profit, they must recover those “losses” through the prices they charge commercially insured patients, most of whom have coverage from their employers. Ultimately, it’s the employer and covered employees who end up footing the bill for low reimbursement levels by Medicare and Medicaid and the uninsured.

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