intro to insurance, part 2

or "why you should give a shit about cpt codes"

i had the kind of call today that everyone in insurance customer service dreads; you get a client calling in to ask about some sort of procedure/test/surgery their doctor has signed them up for.  they doctor said, "you should do this" made them an appointment with another doctor, and no one bothered calling the insurance company to see if it was covered.  needless to say, the person i spoke to today had something very big, very expensive, and very NOT COVERED by their insurance done a few weeks ago.  they got the bill today, and with it quite a shock.  they just assumed that because the doctor said it was a good idea, and they have health insurance, we would pick up part of the cost.  not only did we not, but now the doctor and clinic can bill them for it.  

what surprises me the most, working in health care the last few years, is how many people never ask their doctor what it is they're having done, or why.  granted, nitpicking every single thing your doctor advises isn't a good idea, either, but at some point, you have to be someone who is actively involved in your own health care.  if a doctor says, "i'm recommending this test," it's okay to ask, "why? what do you think it will find?" "what are my options?" or to get some sort of clarification.  if a doctor recommends the latest and greatest test/surgery/medication, be careful.  it might be fantastic, it might be the greatest thing on earth, but it might also be so new that no one knows the long term effects. it might still be under review and study by not just your health insurance company, but by medical professionals.  you might want it, but it might not be covered.  also, if a doctor's office assures you "they'll look into it," that's great, but you might want to do some research too.  finally, you should feel okay asking for more information about the cost.  really.  honestly.  it's not a "cheapskate" thing to do, it isn't gauche, there is no rule against it.  if you know that finances are an issue and have X amount of money set aside for health costs, ask how much you can expect to pay. 

here is where the aforementioned cpt codes come into play.  cpt stands for current procedural terminology.  it may also be called a "procedure code."  if cost is seriously an issue,  ask the doctor or the nice person at the front desk to get you any and all cpt codes for whatever test or surgery you're having done.  along with this, get a diagnosis code (which is sometimes shortened as DX).  what can you do with this information?  you can call your insurance company, have them run the codes, and make sure they aren't an exclusion or exception on your plan, or if they need a preauthorization to be covered.  where i work, it's pretty common for me to run a "test claim," where i punch in all the info about the doc, the test, and the diagnosis, and if something is hinky, i can see it right away and troubleshoot it.  it's not fail proof, the test claim, but it does give everyone a very good idea what the out of pocket will be.  some things are harder to plan for, like anesthesia, facility charges, and unseen medical needs.  you might go in for a routine diagnostic test, and have a reaction to a dye used in imaging and need to go the ER. some stuff you just can't plan for, but knowing as much as you can helps those times happen few and far between.

one thing i'd like to say, and maybe i just feel like i need to say it because i do spend part of my day (every day) getting yelled at and hung up on is this: the insurance company isn't always out to get you.  we might not cover a procedure or surgery, it's true, and that might seem like we're just doing it to be dicks or to avoid paying for it, but sometimes? we don't pay for it because the medical research suggests it's not helpful, or might even be harmful for patients.  also, things change.  just because decades ago everyone decided having a yearly physical was the greatest thing, doesn't mean that it is.  ideas about health and wellness and treatment are constantly in flux.  i'm not saying you need to read every medical journal that comes out, but be open, ask questions, and take some time to think about what you want and what you're willing to pay for it.  it would be awesome if health care was something we didn't have to think or worry about, but it is, and for the moment, it's not free.  it's your money as much as it's your body, and you have every right to be protective of both.