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|Health Insurance Today:
The health care industry has changed dramatically over the past twenty to thirty years. Today's typical health insurance company is a very aggressive business looking to save money in the interest of increasing profits. When computer manufacturers or barbers or car mechanics or psychologists cut corners, reduce quality and quantity of services and increase consumer cost, consumers react by spending their money elsewhere, forcing these businesses to change their practices. Unfortunately, these same market forces have not impacted the health insurance industry as it continues to increase costs to you even while eroding the quality and quantity of service.
No matter the larger socio-political-economics, the day-to-day reality is the same. Your health care is no longer a private matter between you and your health care provider (physician or therapist, for example). In all but a few instances, for-profit managed health care corporations stand between you and your health care provider's recommendations. Managed health care employees who will never meet you, who will never examine you, and who may even refuse to talk to you commonly have the ability to deny you the care that highly qualified health care providers recommend.
Managed health care companies restrict your care and thereby increase their profits in a number of specific ways. It may be important for you to learn which, if any of these business models may be determining who can care for you and how:
1. Indemnity insurance is how all health insurance was fifty years ago. Under an indemnity policy, the patient sees whatever provider he or she prefers, receives whatever care the provider recommends for however long it is recommended and is reimbursed for most or all costs with no questions asked, up to a reasonable per-year or lifetime benefit maximum.
Maintenance Organizations (HMOs)
networks of providers intended to
meet every health care need within
a single organization. Patients
who participate in HMOs typically
enjoy relatively low premiums,
co-payments and deductibles but
may find that they have no
benefits outside of a more or less
limited group of providers.
4. Point of
Service (POS) plans may
cost more in premiums, but offer you
more, as well. Most POS plans invite
patients to see providers on a
preferred provider list (as above)
with minimal co-payments and
deductibles and allow patients to see
"out of network" providers
(those who are not a part of
the preferred provider network) for
somewhat higher co-payments and
5. Capitation shifts the profit-loss dilemma back to the provider. Under a capitated health care arrangement, an insurance company pays a provider a fixed amount of money to meet the health care needs of a specific population for a specific period.
For example, Alpha Insurance pays obstetrician Dr. Smith ten thousand dollars to deliver all of the babies born in Metropolis in a calendar year. If no babies are born, Dr. Smith banks ten thousand dollars for no effort. If ten babies are born, he is effectively paid one thousand dollars per delivery. If one thousand babies are born, he may work non-stop through the year and be paid ten dollars per delivery, no matter whether every delivery is a life-threatening C-section or a fifteen minute uncomplicated labor. Under capitation, providers must consider their own pocketbooks every time a test is ordered or a procedure completed., creating one of the many unacceptable conflicts thrust upon patients and providers alike under managed health care.
|Health Insurance in
the State of New Hampshire
You do have rights. You have a right to appeal any healthcare decision directly to the managed care or insurance agency. Appeals based on a provider's unique services in your geographic area or on a patient's pre-existing relationship with a provider regardless of network status are sometimes granted.
Roger A. Sevigny
603.271.2261 or 800.852.3416
Health Insurance and Mental Health Care
Your health insurance very likely imposes restrictions on the type of psychological services you are eligible to receive and on the allowable duration of such services.
Your health insurance likely requires that the confidential matters which arise in the course of participating in psychological interventions be reported to uninvolved and often clinically naive third parties (e.g., managed health care case reviewers) and that the identified patient (yourself or your child) be categorized and labeled using medical terms suggesting the presence of an illness. These inflammatory and often misunderstood labels are recorded as part of the patient's electronic file. Even the 1997 federal HIPAA laws very likely do not adequately protect this data.
Your health insurance or managed care company requires that participating providers complete reauthorization review procedures on paper, by phone, e-mail or fax which are often very time consuming and highly intrusive, hurdles which can stand between you and the continuation of psychological services.
Always ask the voice at the other end of the phone,
"What is your name and extension number?"
Write it down. Write down
every answer you receive. Don't be intimidated. Ask
for explanations of anything you don't understand. Ask
to speak to a supervisor if you are not happy with the
answers you are getting. You'll need careful records
later if the company fails to follow through with what
they've told you .
"I am (my child is) beginning in psychotherapy.
Am I eligible to file a claim for reimbursement myself?"
Many insurance companies and HMOs will only accept claims for reimbursement directly from the health service provider him- or herself (that is, the physician, nurse, psychologist or other professional providing care).
If "NO," then complain loudly and find a new policy or carrier. The only reason some insurance companies and HMOs refuse to accept claims from you, the patient, is for their convenience.
Keep in mind that your out-of-pocket medical expenses can be minimized if your employer offers a pre-tax medical "health savings account" or HSA.
3. If you are eligible to file your own claims with your insurance carrier, then ask,
Now that you know the facts,ask yourself what you are able and willing to spend to receive the quality of care that you deserve.