1.                   Higher out of pocket expenses.  Traditionally, deductibles are reset every calendar year.  If you had met your annual deductible in 2005 by visiting the hospital or having radiological exams or a surgical procedure performed, you will have to meet your deductible again for services done in 2006.  Check your policy booklet to confirm that your deductibles and out of pocket expenses are based on a calendar year and if so, be aware of your additional expense when having medical treatment or services done.

2.                   Health Plans may change how claims are processed.  If you have a health plan that requires you to submit an insurance claim for consideration and payment, then you should be on the look out for health plans that make modifications to their claims processing.  Sometimes plans get new claims processing systems or sometimes they change the language in the contract and place additional requirements and stipulations on coverage where before the medical service was always approved this year it may be denied.

3.                   As Medicare goes, so do health plans.  Each year there are changes to the description of procedure codes and reimbursement.  A procedure code is a 5 digit code that describes the type of medical service performed, such as code 99222 stands for an initial inpatient visit.  Medicare is a primary driving force that initiates these changes.  Changes could also come in the form of different diagnosis codes, describing the ailment of why the medical service was needed.  Finally,  Medicare will modify their fee schedule each year.  Many health plans use the Medicare fee schedule or RBRVS to calculate what they would pay on a claim, if the RBRVS fee schedule decreases, then it may be possible that the health plan's fee schedule to reimburse your physician for the medical services performed on you would also decrease.  These changes will impact you if you have a deductible or coinsurance amount that you must satisfy.

1.                   Just about everything is negotiable with the health plan.  Exceptions can be made by most if not all health plans once you have coverage.  Exceptions are not normally made for a person attempting to get health care coverage, or to try and get a claim paid for when the coverage had already terminated.  However, if your coverage is still active, the health plan’s supervisor, manager, regional manager, director, or executive may have the ability to make an exception on a claims denial.  It may take some time or the luck of finding a person that is willing to say yes.  But out of hundreds of people working for a health plan, there is bound to be someone to say “yes” we will make an exception and pay your claim this time.  It takes persuasion, making a good case, doing your homework and explaining to them that you have made the effort to research your situation, provide a compromise such as accepting a reduced fee or asking them to make an exception because you did not know the rules, etc.

2.                   Non-covered items, such as those deemed investigative, experimental or cosmetic, may actually be covered by the health plan.  The reason that they are currently not covered, is because they are not common medical practice in the medical community, or they are new types of treatment where the results of the treatment have not been validated.  When you add the expense to an unrecognized medical treatment, health plans are reluctant to cover this.   However, there are studies being performed all the time, and new information about treatments are routinely published.  In order to get these types of services covered by your plan, you must prove to them that there is enough medical data and justification out there that will warrant coverage.  This is done by searching for at least 2 articles from respected medical journals, explaining the results of studies to the treatment.  Also needed is a statement of medical necessity from the physician requesting the treatment.  This information will be presented to the medical board, medical director, of the health plan for consideration.  It works about 50% of the time, if you have all of the necessary, supporting information and you negotiate the cost of the treatment.

3.                   Health plans make mistakes.  When a health plan must consider a claim, it may be automatically processed for payment or manual processed.  If it is automatically processed, the information from your claim must be entered into their system, either automatically from a scanned image or by the assistance of data entry employees who transfer that data.  In both cases, the data entered may not be accurate.  The scanned image may not pick up certain letters or numbers and cause the claim to pay out inaccurately or not process the claim at all.  If the information is manually entered, most data entry people have a 98% error-free rate, which means approximately 2% of all claims submitted will have some type of mistake on it.  When you receive your explanation of benefits, don’t assume that the claim was processed accurately.  Confirm the date of service, medical provider, procedure performed, amount billed, amount paid and the amount you must pay, if there is any.  Not checking your EOB may cause you to pay on something that should have been covered by your health plan.