How do you use your health insurance?

August 20, 2019 8:13 PM

We [spouse + me] have family health insurance through work, with a very high deductible [several thousand dollars]. My understanding is that the yearly preventive exam [free] would become a paid medical expense if we were to tell the doctor something was wrong with us, or if something was found to be wrong, during the exam.

YANMD, etc. Please share how you use your insurance to its maximum benefit, without incurring unnecessary expense. While I am grateful to have it, this issue came up during a discussion with colleagues - most of us do not use our insurance! We pay a fortune, we're not allowed to cancel it, and we can't afford to use it.
- HR and BCBS were not helpful
- we've had the insurance for a few years and have not used it
- previous to that, we had no insurance for several years
- previous to that I had access to health care with my ex-spouse who was in the military

posted by racersix6 to Health & Fitness (14 answers total)

Honestly it depends on the doctor's office and how they decide to bill it. Yes, some offices will not bill any part of the visit as preventative if you discuss any ongoing symptoms or prior issues. My current office does a split billing - say a preventative office visit + a 5-minute office visit, instead of a 30-minute office visit.

If something is discovered *during* the visit (like based on the manual exam or blood testing) it should still count as preventative, but any follow-up visits wouldn't. That is the purpose of the preventative visit. Even more complicated, some blood testing is considered preventative and some is diagnostic (this should be laid out in the fine print of your medical plan). Welcome to health care in America, where we all need to be lawyers and medicare billing experts to get efficient coverage.

The way we use our health insurance, is that when we need to go to the doctor, we do. We shopped around for a good, inexpensive practice (an office visit is about $100). We opened an HSA so that our medical expenses aren't taxed. We pay out-of-pocket until we hit our deductible. We are in our early 30s, one is a cancer survivor, and we have been trying to conceive for several years, so we always plan to hit our deductible and save thusly.
posted by muddgirl at 8:23 PM on August 20, 2019 [6 favorites]

I went through this last year. See my question here:

https://ask.metafilter.com/331805/How-to-contest-a-bogus-insurance-claim-submitted-by-doctor

In short, no idea how to navigate it. As muddgirl suggests, you're basically at the mercy of your doctor's office. I made it quite clear to the office I went to that I was there for the free exam and they gouged me.

When I griped to our HR head about my experience, he said something like, "Well, see, the trick for me is I say to my doctor, 'Now I'm not saying my back is aching, but hypothetically, if a man of my age and girth was sitting here in you office saying his lower back ached...'" And then it might qualify as a free preventative exam where actually something is being prevented.

I've not been to a doctor since that experience. I'm still at the first and most critical step: finding an honest trustworthy provider. I was thinking about trying to make an appointment where I offer to pay cash without getting my insurance involved just to discuss some basic health stuff I have questions about and get a feel for the practice. I expect I'll get laughed out of the network.

I was also wondering if Planned Parenthood was an option. At least in that case, I'd be contributing to a cause I support.
posted by bunbury at 9:35 PM on August 20, 2019

Don’t feel like you’re being taken advantage of. A low-deductible plan with the same network and coverage (and subsidy or absence thereof) would have a hugely higher premium - in other words you would pay much the same “deductible” amount ... only whether or not you got sick or injured!
posted by MattD at 11:07 PM on August 20, 2019 [3 favorites]

if one of you is female, you also get a free "well woman" visit each year that is, at least in my experience over the past few years, separate from the general preventative care visit.

me personally, i have chronic conditions and use the hell out of my health insurance. and i still don't meet my $6,600 deductible.
posted by misanthropicsarah at 6:48 AM on August 21, 2019 [1 favorite]

I use my healthcare all the time. So much so that as a 35 year old healthy person, I went with the top tier plan at my employer because it was only like $30 more a month but I lowered my copays from $40 to $25. Since I go to therapy regularly, that saves me money because all I pay is a copay.

Regular doctors visits - copay
Prescriptions - negotiated rate, usually pretty low (my ADD medicine is $15 a month, was taking an anti-depressant that was 45-50ish per 3 months)
Regular doctor visit - copay, only no copay if I have it as a physical.
Physical therapy for back problem - copay

I've had my regular doc look at my back, refer me to physical therapy, prescribe me ADD/anti depressants, do my blood work recently, have STD tests and of all those only the last one cost more than a copay. The people at the front desk should be able to help and your doctors nurse too, I would think.
posted by OnTheLastCastle at 6:55 AM on August 21, 2019 [1 favorite]

The preventive part of an annual physical is that you mention any concerns and they test for potential problems. Push back with your insurance company because the idea that if anything is found at the annual physical, it's not covered, is nonsensical. Every state has a department that regulates insurance, call them if you need assistance. They'll be part pf the attorney general's web site.

Make sure you get age-appropriate tests like mammogram, colonoscopy (age 50) etc.
posted by theora55 at 8:09 AM on August 21, 2019 [2 favorites]

My understanding is that the yearly preventive exam [free] would become a paid medical expense if we were to tell the doctor something was wrong with us, or if something was found to be wrong, during the exam.

It should say something about this in the mounds of paperwork/online stuff you got (although good luck finding it) during the process of initially signing on to a plan.

Seconding muddgirl and others - the actual yearly exam should be free regardless of what they find. Retroactively charging you additional money for your paid-for-by-your-premiums yearly exam depending on the results of that exam sounds nonsensical, possibly illegal.

Also seconding muddgirl that you should try to pay attention to blood tests, some you will have to pay for and some should be covered, depends on your plan.

How do you use your health insurance?

(Single male, over 50, covered by work with I guess a mid-level deductible so most office visits have some kind of co-pay where I gotta shell out a little money. I intentionally picked non-profit health groups both for GP and further consultation stuff, I have no real idea what kind of difference that might make.)

Step 1) go to GP for general checkup.

Step 2) (just as an example) after covered bloodwork analysis my GP thinks something's a little off, orders more bloodwork.

Step 3) Receive letter in mail from insurance company that lays out charges for that visit and how much of that is covered by insurance. This includes footnotes (!!!!) that often will suggest that some or all of the supposed balance due by me is not in fact due by me because my GP's office has accepted the insurance company's payment as greater or full payment.

Step 4) go back to GP to pull more blood for second round of tests

Step 5) receive bill in mail directly from GP for co-pay for first visit.

Step 6) receive another letter from insurance company similar to step 3 about second round of bloodwork.

Step 7) receive bill in mail directly from bloodwork lab (who I have never ever had any direct contact with and don't even know the company's name so it looks like spam and is likely to get thrown out) for second round tests for outrageous amount of money.

Step 8) call GP's office, talk to administrative personnel about outrageous bloodwork bill. They say they will attempt to do some kind of mysterious claims tweaking.

Step 9) Apparently this works because I receive another letter from insurance company as in steps 3 & 6 about second round of bloodwork with lower but still high cost to me.

Step 10) receive bill from GP for co-pay for second visit.

Step 11) receive another letter from bloodwork lab with new lower total owed.

Step 12) call bloodwork lab, arrange payment plan because I just don't have the lump sum available right now.

Step 13) GP's office calls, second round of bloodwork suggests I could use a specialist, arranges referral to said specialist.

(This entire process can take anywhere from 1 month to a year, 3-6 months being about the average.)

Steps 14 to infinity) repeat all of the above from step 3 onwards, substituting whatever appropriate specialist's offices & treatments for "bloodwork."

Fun, huh?

The TL:DR is that I just go to whichever doctor is appropriate or necessary whenever it is appropriate or necessary, pretty much ignore everything until I get something that is unavoidably and unmistakably a bill, then either pay the bill or call doctor's offices and/or whoever's billing me to try to negotiate a lower price or some kind of payment plan. I generally do not contact my insurance company unless directed to by the doctor's office/lab/hospital.

The American health system is fucked up, but my experience has been that everyone involved knows it's fucked up and will try to work with you.
posted by soundguy99 at 9:19 AM on August 21, 2019 [1 favorite]

P.S. go to the doctor.
posted by soundguy99 at 9:46 AM on August 21, 2019

So there are "well visit" icd billing codes and "sick visit" billing codes. You get one well visit a year (as in do not schedule a well visit 364 days after your last one or your insurance will try to say you got 2 in a year). When you make the appointment you tell the office its for you annual well visit. You will get checked out, asked about your history, maybe have some tests ordered, and if anything is found wrong it shouldnt change that it is a well visit (though you may need to pay for some tests / labwork). Now if at the doctor you say oh also ive been getting headaches... they can bill for the well visit and the sick visit as well, the sick visit you would then need to pay for. If you make an appointment say because you have a sinus infection, then that will be a sick visit and you will pay regardless of weather you had any other visits that year. You should get an eob from bcbs and it should have the billing codes on it so if you think a sick code was added wrongly to your well visit you can contest it.
posted by WeekendJen at 10:41 AM on August 21, 2019

Hi, I used to be a CSR for a major, majorly slimy insurance company. It is very, very common for patients to get stuck with the bill for a "free" physical or a "free" well woman exam. It may be illegal, but it is far from unusual. It's true that it does come down to how the doctor bills, but most doctor's offices, in my experience, don't really care about billing properly as long as they get their money.

My personal strategy is to pay higher premiums so that if I do have health care expenses there's a remote possibility they'll be covered instead of going straight to a four-figure deductible. This industry needs to get put out of business yesterday.
posted by zeusianfog at 3:02 PM on August 21, 2019 [1 favorite]

We have Type 1 diabetes in the family so our strategy is to time out the pump supplies quarterly shipment to hit in January. That plus insulin takes out the $4000 individual deductible on our high-deductible plan , which we spent the previous year saving up for to be able to handle the big expense in January. Then she is on "free" health care the rest of the year. This plan assumes I never get seriously sick, as I'd also have a $4000 individual deductible to deal with.
posted by COD at 5:08 PM on August 21, 2019

Response by poster: Thank you, everyone, I appreciate the info!
posted by racersix6 at 7:59 PM on August 22, 2019

You don't mention this but most high deductible plans offer (or maybe require) an HSA account where you save up money that you can use to pay your deductible as well as any other medical expenses. (Great of out of network counseling when you need a better therapist that you can find in-network). My understanding is that the funds also roll-over so if you don't use your saving one year, you can have them there for future expenses. If you are young and healthy and pretty much never use insurance then maybe that isn't worth it for you.
posted by metahawk at 8:45 PM on August 22, 2019

If you are young and healthy and pretty much never use insurance then maybe that isn't worth it for you.

I have some young and healthy online friends that are maxing out their HSA specifically because they are young and healthy, and have the kind of cash flow needed to put another $3500 in savings each year. The HSA contributions are tax-deductible like an IRA so it's another avenue to save tax free if you are already maxing out your 401K and/or IRA.
posted by COD at 11:24 AM on August 23, 2019