As soon as possible after diagnosis, read your entire insurance manual. Make a list of any questions you have on terms or benefits:
• Learn who the "participating providers" are under the plan, for, in todays managed healthcare climate, there may be a limited network of providers and hefty penalties or no benefits if the patient goes outside the network.
• Determine if your physician needs to document specific requirements in order to qualify for coverage for expensive or extended services.
With our insurance, neuropsychological tests, outpatient occupational therapy, speech therapy, and physical therapy are covered, but the phrasing must be that it is a "medical necessity" due to diagnosis and treatments.
• Find out what your insurance co-pays are for different levels of service (e.g., office visit, outpatient surgery, outpatient testing).
• Find out what your outpatient prescription drug benefits are for generic and non-generic drugs.
• Find out what your deductible is.
• Find out if there is a point where coverage increases to 100 percent.
• Determine if there is a lifetime limit on benefits.
• Find out when a second opinion is required.
• Learn when you have to notify the company about hospitalizations—many firms require pre-notification except in the case of emergency.
I realized that my daughter had been treated for over four months, and I had never called the insurance company. When I read the manual, I was horrified to find out that I had not pre-notified them about three scheduled hospitalizations. There was a $200 penalty for each lapse. I called in tears, and they only charged me for one mistake, not all three.
• Get a copy of every form that you may need to submit—claim forms for inpatient care, outpatient care, or prescriptions. You can cut down on paperwork by filling in all the subscriber information on one of each type of form (except date and signature) and then making many copies. You will have a form ready to send in with each bill.
• Determine whether your policy has benefits for counseling. If so, find out how many visits are covered and the level of training required. (Sometimes only counseling by persons with an MA or PhD degree is covered.)
• Find out the names of approved providers for home infusion supplies (IV medications, central venous catheter supplies, and home intravenous nutrition) and home nursing care. These are often separate companies. Determine policy coverage for these services.
We changed to a new pediatrician, and he asked me if I thought it would be easier on my son to have visiting nurses come to our home to do the chemotherapy injections and some blood work. Since he had very low counts, it made a lot of sense not to have to go out. It also lessened his fears to be able to stay at home and have the same nurse come to do the procedures. It was a pleasant surprise to find these services covered by our insurance.
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