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The Nuances of Health Insurance

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Recently, I needed a minor surgery and had questions about my insurance coverage. I called my insurance company with the medical codes associated with the procedure and was informed that I did not need authorization for the surgery. Given my exposure to such situations as a medical professional, I knew to push beyond that question. I asked several times what that specifically meant: if my specific surgery in my specific situation was covered by insurance and how much the whole procedure would cost me out of pocket. Eventually, with some probing, I received answers.

Some months later, one of my patients needed a similar minor surgery. She called her insurance company with the relevant medical codes and was also informed she did not need authorization for her surgery. She let my team know her insurance was covering the procedure. However, the morning of surgery, we were informed insurance had denied any coverage given her surgical indication and would also not cover any complications that may occur as a result of the procedure. We pushed the procedure back and spent the next few days communicating with the insurance company, explaining why we thought the procedure was necessary and why it needed to cover it.

Though this patient ultimately received her surgery, not all patients are so lucky. This incident, along with many of my other experiences in medical school, only highlights the importance and influence of health insurance on patient health. In particular, as a third-year medical student, I struggled to schedule appointments for my pediatric patients in subspecialty health care clinics due to insurance plan limitations or clinic restrictions on accepted insurances. During my subinternship, I received an email from a patient who told me that her insurance had denied coverage for her multiday hospital stay for an acute illness.  Unsurprisingly, she was concerned about the very expensive hospital bill she received.

Over the years, I have accepted that insurance is an essential component of any medical practice. However, despite formal education on the Affordable Care Act as a first- and second-year medical student, I still do not have a nuanced understanding of how to work with health insurance companies. Just looking at a simple glossary of basic insurance terms convinces me that I, as a health care provider, need to continue to read and research in order to ensure that I am communicating with companies correctly and not accidentally incurring fees for my future patients.

Like my aforementioned surgical patient, many people do not know the medical codes associated with a procedure and may not understand what it means to “not need authorization”; many may believe the procedure is completely covered when they hear that statement. Not only is it important that we improve patient education and help them learn to communicate effectively with insurance companies, but it is also essential as health care professionals that we learn to adeptly navigate the health insurance system ourselves in order to act as the best advocates possible for our patients.

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1 thought on “The Nuances of Health Insurance”

  1. Great post! An additional consideration is that surgeon and facility can be distinct issues - even the anesthesiologist can be a sticking point. Far too complex - we need a simpler system!

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