Tag: health insurance literacy

Is your doctor leaving your health plan network?

Is your doctor leaving your health plan network?

What can you do?

The prevalence of doctors, providers and even larger healthcare groups leaving Health Maintenance Organization (HMO) and health plan networks appears to be on the rise.  While we can appreciate or even sympathize with a doctor’s need to make a change, patients are ultimately burdened with having to pick up the pieces to ensure they have continuity of care, especially if they’re in the middle of being treated for a condition.

Providers leave a health plan network for any number of reasons:

  • Retirement
  • A change in the group’s practice
  • Changing professions
  • Administrative stress that comes with participating in a health plan network
  • Compensation

A provider’s network contract typically gets renewed periodically. One of the most significant reasons doctors will leave networks (or at least threaten to leave) is being unable to negotiate or come to terms on the financial reimbursement of services.  The cost of doing business goes up for every business at one point or another, so who could blame a doctor for wanting to get paid more.  While money is important, sometimes the administrative duties to participate in a network can be too burdensome to manage.

The Financial Impact is Real

If you continue to seek treatment from a doctor who no longer participates in your plan’s provider network, the likelihood is high you’ll end up paying the full charge billed to you, not the lower health plan rate.  If your plan does cover out-of-network expenses, the service will be applied to your out-of-network deductible. While you would get credit applied to the deductible, you probably will need to pay the full charge billed until your deductible is met.  According to Kaiser Family Foundation research, the average In-network deductible for an employer plan is $2,000 for single coverage and $4,000 for family coverage. Out-of-Network deductibles are usually double that of In-Network deductibles.

When a doctor is not participating in a health plan’s network, they are free to charge their normal private rate / street-price.  A $75 In-Network office visit rate would become a $150 or higher rate that you would be responsible for paying now that the doctor is out-of-network.    

When a medical claim is applied to the Out-of-Network deductible, the health plan will still apply only what they think is a reasonable charge for the office visit, and potentially not the full billed charge if higher than their rate. You would only receive deductible credit for what the health plan set as the reasonable rate. 

Higher Reimbursement Rates Could Mean Higher Insurance Premiums

One strategy health care provider’s use to put pressure on employers is to send letters to their patients stating that they plan to leave the health plan’s network because the health plan will not pay for higher rates of reimbursement.  This may come across as a one-sided viewpoint.  Negotiations between health plans and providers occur all the time, especially during contract renewal periods. Such tactics seem to be a way for employees to put pressure on their employers who in turn contact their health plan.

Geographically, one large provider group leaving a network could mean a significant disruption in network coverage.  Health plans want to avoid such gaps in network membership as it doesn’t bode well for their renewal prospects.  Employers will most certainly hear noise from employees who consider traveling a longer distance to find affordable health care. 

If a health plan capitulates to paying higher rates, it could set off a series of unintended financial consequences:    

  • First, other health care providers may get wind of such negotiations and will expect higher rates of reimbursement.
  • Second, higher reimbursement rates could have an impact on the annual premiums come renewal time. While a health plan could try to absorb the higher reimbursement rates overall, eventually it will catch up and bleed into the costs they pass on to employers. Employers don’t like higher premiums as that means their costs go up. The downstream impact will be to pass on the premium increases to employees through employee payroll contributions. Employers could also compensate for higher premiums by changing the plan design like raising deductible levels or reducing the coinsurance rates from say 90% to 80% for In-Network services which still passes on more of the cost to employees.

Individuals who get their health insurance through Marketplace plans (ACA plans) have no real leverage to influence premiums. The only option is to consider changing plans during the next annual open enrollment period to a health plan where your provider of choice is considered In-Network. This change may end up with the person paying higher premiums. In the end, patients end up being the beneficiaries of healthcare inflation which is a real and immediate burden.

What are your options if your doctor is leaving the health plan network?

Typically, the health plan will mail a letter to all impacted members within 90 days of the doctor leaving the network. This assumes the doctor informed the health plan of their departure. You may also receive a letter from the doctor informing you about the change in health plan network status. Most negotiations end in an agreement avoiding departure from the health plan network, or there’s an extension to the contract to continue negotiations in good faith, thereby postponing any impact on patients. Nevertheless, patients are left in limbo wondering what will happen.

In anticipation, you can look for another In-Network provider. This can be a cumbersome, time-consuming process, you’ll need to search the health plan system for a list of In-Network providers and then contact each one to see if they are accepting new members. New patient appointments may take longer than expected so it’s ideal to jump on this as soon as possible.

You may incur a cost to have your medical records transferred to your new provider. These costs are not covered by your health plan.

What if you are currently receiving treatment and prefer to remain with the same provider, or perhaps you live in an area with limited options for a particular specialty? Changing “provider teams” mid-stream can be stressful, and cause delays or even changes in your course of treatment. Often, a provider who leaves a health plan may be part of a larger group of physicians and health care professionals who are leaving the same health plan network. This can impact a wide range of services and treatment you are receiving beyond the office visits to one specialist. You may also need lab work, medical injections, radiology, physical therapy, mental health and other services that have been delivered by those providers within the same group that is leaving the network.

Continuity of Care Option

Your health plan may offer a special process called Continuity of Care, whereby the health plan will make an exception to continue covering all of your treatment by the providers who are leaving the network while you make time to find another In-Network provider. The approval may cover claims for an additional 90 days as In-Network claims.

While on the surface this sounds great, and your out-of-pocket costs may be lowered for the interim period which is a plus, check with your doctor to see if they will continue to treat you and accept the negotiated rate; the provider may expect you to pay full charge regardless.

You always have the choice to continue with the provider on an out-of-network basis assuming they are not retiring. Nevertheless, financial costs weigh heavily on our decisions. Today, medical debt ranks as the top reason for bankruptcies even for people with health insurance.

If your provider leaves the health plan network, there really doesn’t seem to be too many options available other than finding a new provider if you want to avoid higher costs. You can find a new doctor who is In-Network, you can try to change your plan where your doctor does participate, or request a continuity of care option which is not a long-term solution.

Edited by Sebastian Pokluda

18% of Health Plan Claims Get Denied: What action can you take to remedy?

18% of Health Plan Claims Get Denied: What action can you take to remedy?

I believe it’s fair to say people take their health insurance for granted.  They expect health insurance to be there when they really need it. Nonetheless, a misalignment exists between people’s expectations of what health insurance should do and what it actually does. This point is most apparent when a claim is denied by your health insurance company.

The Kaiser Family Foundation analyzes the transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for ACA Marketplace plans annually where over 140 health plans provide health insurance coverage for about 17 million people in the United States.

On average 18% of medical claims submitted to these health insurance plans  are denied.

Based upon our expectations, denials shouldn’t happen, but they do.  A glimpse at the different denial categories sheds light on the misalignment between the health care and health insurance industries raising the question WHY?

Let’s take a look at the major buckets for the denial reasons and try to shed some light on what might be happening, and whether you can do anything to avoid or fix if you have a denied claim.

Contractual denial – coverage excluded for a specific service 16%

The service performed just isn’t covered or included in the plan.

Prior authorization or referral not obtained. 10%

You or your doctor did not obtain (or did not complete the process) for prior approval from the health insurance carrier.

Claim or service was not medically necessary – 2%

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms did not meet accepted standards of medicine. This is still kind of vague, but is the guiding principle.  Here’s a deeper definition from BCBS of Massachusetts.

Experimental or investigational – <0.1%

The use of a service that is not recognized by the Plan as standard medical care for the condition, disease, illness or injury being treated.

Eligibility or rescinded health plan – <0.1%

The patient was not actively enrolled in the health plan for the date(s) of service.

Other Reasons – 59%

While this category appears to be a catch-all, it does include incorrect claim submissions, adjudication or administrative errors. This category interests me the most. While health insurance is technology intensive, it still relies upon manual intervention. People still need to complete a form or performing a task on a timely basis. Additionally, the technology that connect or holds processes together from different vendors or suppliers still needs to work properly. If one of those connections breaks, the downstream impact can be significant.

Most Claims are Not Appealed

In their analysis of the claims transparency data, Kaiser Foundation discovered how the vast majority of people do not appeal their denied claims. Approximately 1/10th of 1% of all claim denials were appealed. Surprisingly, in 2020 37% of ACA plan appeals were overturned.  That’s nearly 2 out of 5 which are pretty are good odds. I would venture to guess that if your claim was denied for an administrative error, nearly 100% of those claims would be overturned by appeal assuming they were eligible services to begin with.

It is unfortunate claims are denied and that we as covered members have to pursue and take action to reverse errors or gaps in care. All we want to do is get treated by our doctor and to have our health insurance help finance that service. We end up having to navigate a healthcare and health insurance system which are not always setup for success.  There are many hidden barriers, roadblocks, and snafus which are out of our control.


If you get your health insurance through an employer or group plan, not through the Open Market plans, I wouldn’t necessarily think you’re out of the woods; your plan could be denying the same percentage of claims.    Let me point out some information to support why we should take pause and believe that the high denial rate is prevalent in all types of health plans:

  • Healthcare providers, doctors who are In-network are the same providers for the most part who participate in the networks offered to employer plans.  Same doctors.
  • Type or kind of healthcare treatment received by people enrolled in these affordable care act plans through healthcare.gov are the same kinds of treatment people get who are covered by employer plan (and probably Medicare).
  • The process to submit medical claims to insurance companies is the same as that for employer plans.
  • The people who work at these insurance companies are the same.
  • The computer systems, logistics, internal networks, pharmacy systems are the same.
  • We’re all using the same healthcare and health insurance system.


Employer health plans are not required by law to report on their claims activity. One could only project that the same percentage and types of denials are occurring with claims that come from employer group or union plans.   It’s the same insurance companies who administer.

In 2021, the number of people covered by health insurance from their employer sits at around 156 million, or 49% of the country’s population.  This is according to research done by Kaiser Family Foundation. That’s a lot of people. This means a lot of claims are flowing through the insurance companies systems.  18% of claims, if accurate for employer plans, is a lot more claims and a lot more healthcare costs being passed on or paid for by the very same people the health insurance is supposed to health in their financing.

What actions can you take to avoid or handle your denied claims?

  1. Ask up front whether the treatment your doctor is about to provide or recommends is covered by your health plan. 
  2. If referred to a specialist for a special procedure ask up front if you need a referral.
  3. Retain and provide your latest health plan ID Card to your healthcare provider at the time of service.
  4. Verify timely that the claim was processed/paid by the insurance plan as expected
  5. Read the Explanation of Benefits statement (EOB) online before you make any payments to your doctor. 
  6. Engage your In-Network provider to go to bat for you.
  7. File an appeal. It’s the official way to put the insurance carrier on noticed and they have to respond.  
  8. If you get health insurance through your employer, ask your HR or Benefits contact for assistance. Can they get someone at the insurance company (account rep) to help intervene.
  9. After you’ve exhausted other measures timely, you can contact your local state insurance department, they may have an ombudsmen or insurance complaint department who investigates. They will at the very least send a letter to the insurance company requesting details on your situation.  Insurance companies are accountable to these entities at least in providing visibility and getting an accurate assessment.

In summary:

  • Pay attention to your claims on a timely basis
  • Use the insurance website to track your claims
  • Ask up front if your treatment is covered
  • Don’t assume what you’re billed by the doctor is accurate or what you owe
  • Keep notes

To learn more about how to improve your health insurance literacy, listen to the Maximize Your Health Insurance Podcast series which is based upon the book Maximize Your Health Insurance authored by William J. Pokluda available on Amazon.com.  

Is our Health Insurance Literacy improving?

Is our Health Insurance Literacy improving?

Health insurance literacy or HIL is a foreign concept to most people, but if understood and achieved at even basic levels, one can yield long-lasting effects on their health. The greater one’s understanding of health insurance the higher the likelihood for access to health care, getting medical treatment and ultimately staying healthy.  Nevertheless, health insurance literacy continues to remain at low levels in the United States.  

Defined by the Health Insurance Literacy Expert Roundtable, health insurance literacy is the degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own or family’s financial and health circumstances, and use the plan once enrolled.  The degree of HIL that one possesses falls on a spectrum from none to high.

In 2003, the U.S. Department of Education conducted a National Assessment of Adult Literacy and found that one’s overall health (from poor to excellent) is a function of the level of health literacy, and that your level of HIL correlates with which type of insurance you have: employer-sponsored, military, Medicare, Medicaid or uninsured. However, the average literacy scores of those with poor health compared to those with excellent health varied, but not significantly.  53 percent of adults had Intermediate health literacy. About 22 percent had Basic and 14 percent had Below Basic health literacy.

In 2010, shortly after the Affordable Care Act’s (ACA) went into effect, the Kaiser Family Foundation conducted a survey to shed light on Americans’ understanding of basic health insurance terms and concepts. Over half (52 percent) answered at least 7 out of 10 answers correctly, with only 4 percent answering all 10 questions correctly.  Using a grade-school scoring method, the remaining 44% would not have received a passing grade.

(Take the Kaiser Family Foundation 10-question quiz to identify your level of literacy with health insurance terms and compare yourself to others who took the quiz. You may be surprised to learn you’re as smart as a sixth grader.)

With several years of enrollment and experience in ACA health insurance exchanges, the expectation is HIL would increase.  Think again. In an analysis performed by the Institute for Healthcare Advancement in 2019, they found more than one-half (51%) of survey respondents had inadequate HIL as measured by knowledge of health insurance terms, and close to one-half (48%) had inadequate HIL as measured by confidence in health insurance use.  

If people are not grasping even the basics of health insurance or feeling confident in using it, how can we expect them to be active consumers of health care services?  Knowing how to find a doctor, fill a prescription, obtain and pay for a medication, understand the medical provider’s explanations, as well as insurance EOBs are all measures of health literacy.

HIL is not taught in school. Often, people learn about health insurance through a baptism by fire experience. If we receive a significant charge or invoice in the mail from our doctor, a common thought is “I thought my insurance covered this?”  Unwittingly, people put a lot of reliance and trust on a medical community who is driven by revenue and on an insurance system designed to minimize their risk.  Motivated financially, people become investigative sleuths navigating an itemized billing labyrinth to only discover they didn’t meet their deductible or went out-of-network not by conscious choice.

The healthcare system is flanked by healthcare providers on one side and health insurance plans on the other leaving employees figure out how it all works. If they’re lucky, their employers can step in to help.

Political efforts attempt to fix problems in our healthcare system to make it fair for people, like surprise medical billing, but legislation cannot address unintended consequences. Our healthcare system is financed by fee-for-service players driven to maximize revenue through itemized billing, and with minimal or no upfront transparency to the patient in any consolidated manner.

HIL continues to be an uphill battle for employees.  

Years ago, High Deductible Health Plans (HDHP) with Health Savings and Health Reimbursement Accounts were designed to be the great equalizer motivating people (begin treated like consumers) to take more ownership in their healthcare decisions.  Now, with over 40% of Americans enrolled in a HDHP, you would expect HIL to have increased.

A study published in Health Affairs, March 2019 illustrated how most people are not engaged in consumer behaviors.  Only one in four enrollees (24.9 percent) had even talked with a medical provider about how much a service would cost. Fewer had compared prices for a service at different facilities (14.4 percent), compared quality for a service at different medical facilities (14.0 percent), or tried to negotiate a price for a medical service (6.5 percent).  The perception of futility fuels a lack of engagement in consumer behaviors.

Employers, insurance companies, the government and even non-profits offer tools and resources for people to learn about health insurance. Ultimately, people need to take action to learn how to be active consumers and increase their health insurance literacy, and not wait for a health care system to change.