November 1, 2013
By Jonathan Sackier
The number-one cause of bankruptcies? Massive medical expenses—so dodging disease makes sense. The next four causes? Job loss, buying a turbine with piston income, devastating floods, and divorce. I cannot help with employment, spending habits, natural disasters, or love life—but a few health pointers? That I can do.
Airmen are not doing all they can to avoid illness; many aviators—fearful of losing their medical—decry disease-screening modalities or ignore early signs of impending doom. From both the financial and medical perspectives, it is sensible to be proactive; address your health first, and then your flying privileges.
Fire insurance became common in the 1600s and, with a burgeoning industrial society, other coverages arose. Around 1850, the Franklin Health Assurance Company of Massachusetts offered financial support for those injured on steamboats or railroads, and the practice grew from there. While paddlewheel amputations or hammering a railway spike through your foot may be rare today, obtaining and understanding coverage is key, given healthcare costs. As a physician I can state with impunity that navigating the system is like flying a back course ILS in turbulent nighttime IMC while running low on fuel with hysterical passengers. That is why it makes sense to have an instructor on board—mine is Jon Katz, who has served as my insurance agent for many years. Katz told me, “Get the facts and choose the right plan for your needs. The investment of time will pay healthy dividends.”
The Veterans Administration provides care for ex-military, while active servicemen and women are cared for within the forces. Medicare insures older people, and Medicaid is a safety net for low-income Americans. Our legislators have rather appealing healthcare insurance benefits that have made me consider running for office! Many folks are covered by employers who “self-insure”—they pay for care directly with no third-party financial institutions involved. If this is your circumstance, confirm your employer has “catastrophic coverage” in place—if a high-risk pregnancy, organ transplant, or major trauma occurs, costs can be astronomical, and you do not want to be responsible for such charges. These policies can also be taken out by individuals who are effectively paying a high deductible and betting against more routine healthcare costs.
Health maintenance organizations (HMO) offer provider and facility networks; patients pay for outside service. Preferred provider organizations (PPO) offer either completely covered care (CCC) or partial coverage (PC). Point of service plans (POS) do not require referrals for in-network care (INC). High deductible health plans (HDHP) are yet another flavor, and health savings network plans (HSNs) allow reserving pretax dollars to cover costs. Each time I review the options, I get a headache (IGAH).
The Affordable Care Act, while rather dull reading, has many provisions impacting this space, and I heartily encourage you to become familiar with relevant parts of the legislation.
Prior to any care delivery, in or out of network, ascertain whether a formal primary care referral is required and what your costs may be. Before scheduling procedures, ensure prior authorizations and relevant qualifying tests are ordered and documented. Retain copies for your records; it is good insurance and may prevent difficulties. Should treatment be denied, do not roll over—you are the PIC (patient in command)! Read denial letters carefully to clarify the problem and define appeals processes. Call the prescribing physician, since a coding or billing error can cause denials. Maintain logs of every call, email, and letter, and send by traceable means. Common reasons for denial include insurers believing treatments are not medically necessary, are experimental, or coverage does not apply to that given physician or location. Your doctor is your advocate, and the state ombudsman may be helpful.
As noted, physician coding impacts your life; doctors must correlate diagnoses (International Classification of Disease, or ICD) and treatment (Current Procedural Terminology, or CPT). Currently, we use ICD9, with its 13,000 codes. In October 2014, ICD10 arrives with more than 68,000 codes! Confusion will be compounded with codes such as W5922XA: struck by a turtle or V9542XA: spacecraft crash injuring occupant. Amazing.
Financial uncertainty accompanies anyone entering a doctor’s office; what is and is not covered? Can you challenge coverage decisions? Before signing, review the policy language as it relates to your needs—get an agent’s advice! Be alert to the plethora of Internet insurance scams, and regardless of which alphabet soup plan you choose, avoid the Northern Occidental National Engagement plan (NONE).
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