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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.


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

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    You definitely want to make sure the doctor and/or medical practice (a group of doctors) are "in-network." Another gotcha is when certain services are billed through a hospital rather than through a doctor's office. The former can end up costing you the deductible plus extra. You should talk to co-workers and HR about any issues they've had. – mkennedy Jan 19 '16 at 3:26
  • @mkennedy Thanks, good point 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. – Franck Dernoncourt Jan 19 '16 at 3:32
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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.

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    Thanks. 1. "When you go to see a doctor, you have a general idea why" -> sometimes yes, but not always. 2. "although some are explicitly covered" --> I don't have the exhaustive list of it. How to know? 3."medically necessary " -> that sounds subjective. I guess each insurance has a list of code they regard as medically necessary, but I don't have such a list. 4. "you can ask them to run it through the insurance first. " -> they are not legally bounded to say a correct estimate, so I don't trust their financial assessment (first-hand experience, twice). – Franck Dernoncourt Jan 19 '16 at 15:10
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    @FranckDernoncourt the list of conditions that are not medically necessary but are still covered should be available to you from your medical provider. Usually these are contraception, screenings and preventive care. Medically necessary is not subjective at all. If the doctor says it is medically necessary - then it is. – littleadv Jan 19 '16 at 23:30
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    Bottom line is that there are way too many options for an "exhaustive list" to be feasible. You'll have to ask a question a tad more specific than you have. That's probably the answer you got from your insurance provider as well, isn't it? – littleadv Jan 19 '16 at 23:31
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    @FranckDernoncourt "not legally bounded" - yes they are. Don't know exactly what your experience is, but when you get a quote from the insurance company, it is always legally binding. Obviously if the details of the actual charge differ - the quote won't be valid any more, but then - ask the clinic why the final charge was different. – littleadv Jan 19 '16 at 23:33
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    @littleadv I disagree with a lot of what you're saying. There have been too many reports of health insurers agreeing to cover a treatment and then later rescinding by finding a 'mistake' in the patient's original application. A Dr can say a patient needs something "medically necessary" but if it isn't widely accepted practice or new treatment, ins can still refuse. – mkennedy Apr 2 '16 at 14:32
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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.

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  • This provider "BreakThrough" sounds not like a regular doctor or hospital, but rather part of the gray area of health-related services that are "sometimes" covered by US health insurance. It may not be covered at all... – krubo Mar 2 at 9:30
  • @krubo BreakThrough provides physical therapy services, which is pretty much always covered by US health insurance (potentially requiring some referral, just like when going to medical specialists with non-PPO plans, and sometimes with a maximum number of visits per year and within 24 hours, etc.). – Franck Dernoncourt Mar 2 at 9:57
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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.

  • "They said they are bound by the code submitted by the doctor, and changing the code would be fraudulent." -> I got that line too one day, also due to some billing mistake… – Franck Dernoncourt Mar 2 at 9:58
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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.

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