14 Secrets Every Health Insurance Company Knows (And You Should, Too)

Before you invest in health insurance, make sure you know just as much as they do. (Photo by Getty Images)

Calling your health-insurance provider is right up on the Most Dreaded List with getting a colonoscopy. But there will come a day when you can’t avoid calling that toll-free number, pushing 2 for English, 4 for Claims, keying in your 47-digit Group ID number, having your 47-digit Group ID number electronically read back to you, and then (finally!) being told your wait time is 50 minutes. But there is a better way. We actually got through to these insurance people (and other experts) and asked how to make this whole process more efficient. Here’s what they told us:

1. Don’t call on Monday.

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This is like trying to get through to the Heavenly Ham store the week before Easter. You’ll be on hold forever, along with everyone else who had questions arise over the weekend, says Elisabeth Schuler Russell, founder and president of Patient Navigator, LLC. Try Wednesdays, Thursdays, or early Friday before people start wrapping up for the weekend, she says.

Related: 13 Ways To Lower Your Blood Pressure Naturally 

2. Be prepared before you call.

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Have your insurance card and the document in question (medical bill or insurance company statement) handy. If you’re calling to see if an upcoming treatment will be covered, have the diagnostic and procedural codes from your doctor. Being prepared also means having something to do while on hold. Multi-tasking will ease your stress.

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3. Sweet-talk ‘em.
Even though your inclination may be to curse and scream when someone finally picks up the phone, remember that’s a human being and this isn’t her fault. “Be collaborative and never throw gasoline on a fire,” says registered nurse and patient advocate Teri Dreher, CEO of North Shore Patient Advocates in Chicago. “Be exceedingly polite; say 'thank you’. Use her name, and show the impact their assistance had, if you can.” Being nice makes it more likely they’ll go the extra yard for you.

4. Understand your plan.

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Most people read the “101” version of their benefits, typically a pamphlet or PDF summarizing coverage. But if you’re contesting something, you’ll want to have the “201” version, says Russell. This is called the “evidence of coverage” or “certificate of insurance,” and it’s typically much heftier—sometimes up to 200 pages. It may be mailed to your home or posted online, but sometimes you have to request it. Then you can ask the rep, “Could you please point me to the document you’re referencing?” says Dianne Savastano, founder of Massachusetts-based Healthassist, which helps patients navigate the insurance system.

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5. Record everything.
The automated voice that says, “this call may be monitored…” is good advice for you, too. Note the date and time, the name of whomever you spoke with, and any details about what they said, so you have a documented version of the conversation just like the insurance company does. In fact, you can record the conversation as well.

"Very few insurance-related calls are resolved in one phone call,“ says Russell, so it’s likely you’ll need to reference this info when you call back. "If you can say, 'I talked to Jasmine on June 6 at 3 o'clock, and she told me this,’ you may not have to explain the whole thing from scratch.”

Another option is corresponding via email. You won’t have to take (as many) notes if everything is in writing. Ask the rep if you can follow-up via email and, if he agrees, ask if you can send a note summarizing your phone conversation, says Savastano.

6. Insist they speak English.
Insurance-world jargon can be intimidating, so don’t be embarrassed to say to a rep, “Help me understand what that means,” says Scott Josephs, MD, national medical director for Cigna Health Insurance. Here are some common terms and their meaning (find more at Healthcare.gov/glossary):

• Deductible = the amount you will     pay before your plan kicks in at the rate outlined in your benefits     summary

• Out-of-pocket maximum = the     most you will pay before your plan covers 100% of your charges

• Copay = a fixed amount you’re charged for     health care covered by your plan, for example $15

• Allowed amount = the maximum your     plan allows a doctor to charge for payment on covered health-care     services, for example, $100 for an in-office visit. This is sometimes also     called the eligible expense, payment allowance, or negotiated rate.

• Coinsurance = a percent you are     charged of the allowed amount for health care covered by your plan, for     example 20%

• Medically necessary =     the health care services that meet your insurance company’s standards of     what medicine is truly needed for diagnosis and treatment

7. Get some respect.
Once you’ve mastered some insurance jargon of your own, use it. Using the proper terminology can communicate you mean business, Savastano says. “Could you please walk me through how this claim was processed?” is a good start. Or “Could you please detail how this claim was adjudicated according to the benefits?” You’ll get some satisfaction regardless of how the conversation turns out.

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8. Ask to speak with a nurse.

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That’s right, many case managers at insurance companies are registered nurses, explains Dreher, and they’re usually more knowledgeable and sometimes even more sympathetic to your cause. So if you need assistance with a medical question and your customer service rep isn’t being helpful, ask politely for an RN. (Looking for more ways to adapt a healthier lifestyle without medical professionals? Check out Heal Your Whole Body—and see how to lose 13 pounds fast.)

9. Follow up.
If the insurance company promises to get back to you by a certain date, put a reminder in your calendar to follow up immediately after you hang up, says Savastano.

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10. Always get it in writing.
If the insurance company is making an exception to coverage rules, get that agreement in writing. Dreher had a client in Illinois who needed a complicated surgery that no in-network, local provider could perform. The most experienced surgeon was out-of-network in California. The patient’s insurance company verbally agreed to cover the procedure, but afterward he received a bill that didn’t line up with what had been promised. Fortunately, he had documented every detail, and Dreher helped him file an appeal.

11. Don’t pay until these numbers match.
After a medical appointment or procedure, you’ll receive an “explanation of benefits” from your insurance provider as well as a bill from your doctor. Both documents will specify how much money you owe the doctor. In a perfect world, these two numbers should match, says Russell. If they do, pay that amount. If there’s a big discrepancy, call the doctor’s office to make sure it billed the insurance company correctly. Just because $600 may be the average rate for that procedure, a doctor could charge $1,000 simply because she did it at a different hospital.

While insurance companies generally won’t budge on discrepancies like this, hospitals and doctors might, says Dreher. Ask to speak with a medical advisor at the hospital or doctor’s office and explain any financial stress you’re under. But instead of asking for the entire bill to be waived, offer to pay a sizeable portion (say 50 to 60%). At the very least, you could get a more reasonable payment plan, says Savastano.

12. Set up a conference call.
There are strict rules protecting your privacy when it comes to health care and health insurance—and rightfully so. But things can get frustrating when you’re trying to help, say, an aging parent. Savastano suggests a conference call between you, your parent, and the insurance company so the rep can validate your parent’s information and get her okay to speak with you. If this is something you’ll be doing regularly on behalf of a parent, consider filing a power of attorney with the company.

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13. Stop using out-of-network providers.
Obviously, in an emergency you go where you must. But when it’s not, using an out-of-network health-care provider is a sacrifice, Josephs says. “For out-of-network providers, your deductibles and coinsurance are often higher, and they haven’t gone through the rigorous quality criteria that we have for in-network providers,” he explains. All of which may add up to more expense and headaches for you.

14. Know what you’re buying.
Half of those surveyed by Cigna in a recent poll admitted to spending less than one hour deciding on their health insurance coverage. You wouldn’t buy a car or even plan a vacation with that little sweat. If you get your insurance through an employer, you’re probably guilty of this, says Savastano.

“Spend the time to make the choices that are right for you,” says Josephs. Be aware that choosing the employer-offered plan with the lowest premium might not save you money. It depends on what kind of care you need, such as behavioral health services or prescription meds.

Open enrollment season will start soon. Don’t blindly go with last year’s choice. Investigate the changes and any new options. Having the right plan—and knowing it—is the best way to remove this chore from your Most Dreaded List.

By Sarah Klein

This article ‘14 Secrets Every Health Insurance Company Knows (And You Should, Too)’ originally ran on Prevention.com.