News & Updates


Sean Shaw: Understanding your health insurance

Published: Monday, April 13, 2009 at 9:03 p.m.
Last Modified: Monday, April 13, 2009 at 9:03 p.m. 

In my position as Florida’s Insurance Consumer Advocate, I often hear about how health insurance is letting our citizens down. Most often the complaint is that health insurance benefits are decreasing thereby leaving many people owing substantial amounts to health care providers after their health insurance has paid its share. 

Due to rising health care costs, many health insurance plans have reduced covered benefits and pay less for what is covered. This can create overall confusion as to how our health insurance works. In the past major, medical insurance provided coverage when we went to the doctor, hospital, pharmacy or other health care facility. One just presented their insurance card, paid what they were told – which was usually very little – and went on our way.

Now there are Health Maintenance Organizations (HMO) plans, Exclusive

Provider Organization (EPO) plans, Preferred Provider Organizations (PPO) plans and hybrids or combination plans that we must try to navigate. These plans control costs by limiting coverage to a select group of health care providers. Insured’s mustuse these “in network” providers in order to maximize coverage. Given this framework, it is easy to make a misstep and end up owing health care providers a lot of money. In addition plan managers, as opposed to the treating doctor, have increasing power to decide how and when benefits may be used.

HMO plans have strict requirements to see only their providers; generally a primary care physician will control and direct your health care. You must go to the HMO’s hospitals, doctors or pharmacists. It is up to you, the subscriber, to verify that the providers are in the network. The only exception is for out of the coverage area emergencies, in that situation you are required to notify the HMO. Florida statutes outline the payment protocols in this situation.

Some HMO plans have provisions called Point of Service (POS) riders that may allow you to go to a doctor out of the network, but there are usually strict requirements, prior authorizations to obtain, deductibles, co-payments and co-insurance to be paid. Additionally, if the provider charges more than the HMO allows, you are responsible for the difference. The POS rider gives you some added freedom, but make sure you understand the restrictions and cost.

EPO plans are similar to HMO plans in that you usually select a primary care physician who decides whether or not you can go see a specialist. You are limited to a restricted group of network providers and if you go out of the network there is usually limited coverage or no coverage at all.

PPO plans resemble historical major medical coverage, but with different benefit levels. Usually the highest level of coverage and protection comes from using “in network” providers. You generally have lower deductibles, lower co-payments and lower coinsurance to pay. You also have protections from “balance billing,” whereby the network provider can’t charge more than the pre-negotiated amount.

In this type of plan you usually have a lower level of benefits if you choose to go “out of network.” You have the freedom to select any provider you choose, but selecting “out of network” providers will generally subject you to higher deductibles, higher levels of co-payments and coinsurance. You are not protected from balance billing. In other words, you are responsible for the difference between what the health insurance allows and what the “out of network” provider or hospital charges.

Sometimes these differences can be substantial. This can be especially problematic when being treated in a hospital. Many hospitals subcontract with radiologists, anesthesiologists, pathologists and emergency room physicians who may not agree to accept the discounts the hospital has negotiated. You may go to the “in network” hospital and end up being treated by subcontracted providers, each of which may bill you separately.

Here are some tips to prevent unexpected costs:

Read your insurance materials carefully

Your insurance plan may only cover “in network” doctors. They will be listed in a provider directory, but it is best to check on the plans website and verify with the provider.

If your plan does not cover “out of network” care, you will have to pay the whole bill.

If your plan does cover out of network care, you will still have to pay part of the bill. You usually have to pay more for “out of network” care and you DO NOT have protection from balance billing.

You may have to get your health insurance plans approval before you go “out of network” or before your have certain medical procedures.

Your insurer may cover some “out of network” care in emergency situations or in situations where their network does not have provider of the specialty you need.

Ask Questions

Ask whether your doctor, hospital, facility, or pharmacy is in your specific health insurance plans network. DO NOT ASK IF A DOCTOR OR HOSPITAL TAKES YOUR INSURANCE! This question is far to open ended. Too many different plans are offered by each insurer, they may offer HMO plans, EPO plans, PPO plans, etc. A provider could be “in-network for the PPO, but not for the HMO. If this is the case, and you are in an HMO, you would be “out of network” if you received services. If you have doubt,

call the plans 800 number or visit their website and inquire. It is your responsibility to verify the participation status of the providers you use.

If you are planning to go to the hospital, ask if your doctor and all treating doctors are “in network.” Even if the hospital is “in network,” your treating doctor may be “out of network”, which will cost you.

Get help understanding your insurance plan, its benefits and restrictions. Inquire with the doctors billing coordinator, your employer’s benefits coordinator, or your insurance agent.

Take notes; get names, dates and times of everyone you talk with regarding claims, bills and disputes. Keep all correspondence, including postal stamped envelopes.

Evaluate the Cost Ahead of Time

If you are going “out of network,” ask for the billing codes, known as CPT codes in advance of the treatment, then share them with your health care plan to see if there will be coverage. Ask for this information in writing – both for the code information and from your health care plan regarding coverage. You may also ask if the doctor will

discount the work, they may prior to service, they usually won’t afterwards.

Prior to receiving service, verify whether or not you need prior authorization from your primary care physician, or your plan.

Verify whether or not you need to satisfy any deductibles and how much.

What to do if your health care plan denies your claim or pays less than you think should be paid

You have appeal rights. Read your plan document and it will outline your appeal procedures. You may also check with your employer or your agent.

HMO plans have an additional statutory appeal procedure following appeal denials through the plan. It is called the Statewide Subscriber Assistance Panel. HMO plans are required to provide instructions for appealing to the Panel. If you can’t pay, try to negotiate the bill and payment plan with your doctor or hospital.

Be wary of credit card offers to cover medical bills. The interest rate may be very high, or start low and change to a higher rate without notice. Your doctors billing coordinator, or your employers benefit manager may assist you in filing claim forms and appeals. The Department of Financial Services, Division of Consumer Services at 1-877-693-5236 or visit may be able to assist you by intervening with your health care provider. Consumer assistance guides are available on line.

The Insurance Consumer Advocate is appointed by Florida Chief Financial Officer Alex Sink and is committed to finding solutions to insurance issues facing Floridians, calling attention to questionable insurance practices, promoting a viable insurance market responsive to the needs of Florida’s diverse population and assuring that rates are fair and justified.

Sean Michael Shaw is Florida’s Insurance Consumer Advocate