How to be sure a medical appointment will be fully covered by a health insurance in the United States?

Question

I have recently moved in the United States, and I have a health insurance through my local employer. How to be sure a medical appointment will be fully covered by my health insurance in the United States? (or at least that I will only have to pay a fixed copayment.)

Here are the options I have considered:

• if I call the health insurance's customer service prior to my appointment, neither I nor the customer service can guess in advance the diagnosis and procedure codes the physician will bill me for.
• if I call the physician prior to my appointment, they cannot guess in advance diagnosis and procedure codes they will bill me, because it depends on what will happen during the appointment.
• the health insurance refuses to provide a listing of procedure and diagnosis codes that are covered upon request.
• asking the physician whether the appointment is covered is pointless as nothing legally bound the physician to be correct regarding insurance coverage, and he may simply say he does not know.

None of these options work. What shall I do? Bills can be pretty expensive in this country, even a simple medical appointment may be bill for ~500 USD.

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Answering mkennedy's comment: I can check (and I do check) whether the physician is in-network prior to the appointment. But even an in-network physician may result in an uncovered appointment (first-hand experience). Co-workers do share some information, but of course nothing legally binding and information is partial, so it's really not enough. Also it's not so great for patients' privacy. HRs refer me to the insurance's customer service

Answer 1

You should know from your insurer what is your co-pay, and what is your deductible. Co-pay is what you pay each visit. Deductible is what you pay before the insurance kicks in. There's also the annual cap on the maximum out of pocket payment, after which the insurance will pay everything.

Health insurance only covers medically necessary treatments/procedures, so you will not be covered for elective things (although some are explicitly covered). Usually, when you go to see a doctor, you have a general idea why. If the procedure they suggest is not medically necessary - you can ask them to run it through the insurance first. Dentists do it routinely, medical doctors however usually bill insurance after the fact. They will ask for insurance pre-approval if you're willing to wait and not going to die while waiting, if you ask them to.

Answer 2

Based on my experience with Aetna and Blue Cross Blue Shield Association health care companies you cannot be sure that a medical appointment will be fully covered by a health insurance in the United States.

Some of medical providers and customer service members state it upfront.

Example from Aetna customer service:

Question: is it possible to have a guarantee of coverage before visiting a medical provider?

Answer from Aetna customer service: No, we do not provide guarantees on benefits. The provider can submit a pre-determination in writing including records and the proposed services. They will receive a verification of whether or not the services meet the criteria under you plan but it still would not be a guarantee as the services do not need authorization so we will not make a benefit determination till we receive and process claims for the services.

Example from the medical provider "BreakThrough Physical Therapy, Wellness and Sports Performance":

I want to receive these services and understand that my insurer will not decide whether to pay unless I receive these services.

Answer 3

My experience was that it's not possible.

Specifically, most US healthcare plans cover certain "preventive care" without any copay or deductible. Supposedly this includes a physical examination. However, I wasn't able to get my insurer (Aetna) to provide the diagnosis/billing codes that they consider to be "preventive care". And I wasn't able to get my doctor's office to provide the diagnosis/billing codes that they would use for my appointment because they said the doctor would make the determination. The doctor said he didn't know how the billing would work.

In the end I ended up paying $170 (for deductible) for a physical examination, because it was billed as if I had an actual sickness. After getting the bill, I questioned the doctor's office again about whether it was billed under the correct code. They said they are bound by the code submitted by the doctor, and changing the code would be fraudulent. (Rant: But I'm the victim of fraud when I paid for the insurance and they're making me pay for what their contract says is covered, right??) So I just paid it.

Answer 4

The closest you can get to avoiding unexpected bills is to use a Health Maintenance Organization. An HMO is a combination of insurer and provider, so you are less likely to be caught by a difference between what the insurer considers reasonable and what the provider actually charges.

That said, US medical billing is incredibly arcane. This month I received both a check for $60 from my HMO returning an overcharge, and a bill for $60, with the same date.