• Insurance

How To Ensure Your Insurance Will Pay For Your Surgery

Life in the Trenches of the Health Insurance Business

By Scott Golden and
Stephanie Cohen

This month’s health insurance issue: Linda is having surgery in the morning, but at 4 p.m. the afternoon before, she gets a call from her HMO requiring her to post a $400 advance deposit — or the surgery is off. What should she do?*

The situation: Our client Linda was scheduled to have surgery using a surgical group that had negotiated fees with her HMO carrier. Besides being told to post $400 in advance, she was told she needed to sign a form stating she would pay whatever fees the carrier would not pay to the doctor.

This came despite the fact that the surgeon was in her HMO network and Linda had gotten the proper referral and authorization from the carrier. In fact, her policy dictates that when a provider has signed a contract with an insurance carrier, the patient is held harmless from all fees associated and cannot be asked for additional payments other than applicable copays, deductibles, and coinsurance. In this case, the policy had a $20 doctor copayment and 100% coverage, with no hospital copayment.

Linda called us in a panic, and we immediately phoned our contact at her HMO. Due to the late hour, our contact couldn’t do anything until the following morning, when she would have a representative from provider relations step in. And after a long discussion with the insurance company, Linda did not have to post the deposit and did have a successful surgery.

The solution: Don’t assume anything before having surgery. Get on the phone and make sure you are covered.

1. Contact the insurance provider and verify all benefits. Always get the name of the representative you talk to, as well as the department name and number. Try to speak with a supervisor. Also, note the date and time you had the discussion, since all calls are recorded and can be pulled to make sure accurate information was given.

2. Get all pre-authorization agreements in writing. Typically, the doctor’s office will call, but you should insist on getting it in writing, too, so you can be sure everyone involved in the surgery — the surgical center, hospital, anesthesiologist, doctors, etc. — is covered by your health insurance plan.

3. Understand your policy and be clear about the items that you may be required to pay for. Many hospitals, surgical centers, radiological providers, and labs will send you a bill in addition to submitting it to the insurance company. Remember:: Never pay a bill unless the insurance company has received it first and re-priced it (including applicable discounts) and until you have received evidence of benefits that match the bill.

The painful truth: Unfortunately, the system is broken. Insurance carriers, doctors, and patients will continue to eek out whatever they can from the health-care and insurance system until new policies are in place that make it clear exactly what the contract is that they are entering into. If anything is unclear in your agreement, a new one needs to be worked out that will include cost, payment, and what insurance covers.

If we were the Health Insurance Ambassadors: We would require that all doctors notify the patient about the exact cost of the surgery before the procedure. The patient would then have a full understanding of the costs associated with the surgery and the doctor would receive the appropriate payment.

In defense of doctors, we would also change how they take payments. Doctors do not ask for money upfront. They provide a service and hope that they will receive payment afterward. Perhaps they should swipe a credit card before the procedure or at the time of an office visit.

About Golden & Cohen

Husband-and-wife team Scott Golden and Stephanie Cohen co-founded Golden & Cohen, in Gaithersburg, Md., in 1992 and have built it into one of the top-rated health benefits companies in the Washington, DC, area.

Scott Golden, chief financial officer, is recognized as an industry leader in the small to mid-size insurance market and ranks among the area’s top producers, according to the Washington Business Journal’s annual list.

A native of upstate New York, he received a bachelor’s degree in marketing from the University of Maryland in 1985, an MBA from George Washington University in 1990, and later a JD and LLM in taxation from the University of Baltimore. His advanced academic and legal degrees enable him to evaluate local and national mandates to help his clients find the health insurance that best suits their needs. He also advocates for lower health-care rates on behalf of his clients.

Supporting the community is important to Scott, who has served on the Green Acres School Board of Trustees and sits on the board of ALS-DC in Maryland.

Stephanie Cohen, chief executive officer, has helped grow Golden & Cohen into one of the largest female-owned companies in the Washington metropolitan region.

With more than two decades of experience in small group health insurance, disability programs, and life insurance, she was a finalist for the Ernst & Young Entrepreneur of the Year Award and serves on the prestigious United HealthCare, Coventry, Aetna, and Kaiser Broker Council. She is also a member of the Women’s President Organization, the District of Columbia Insurance Commissioner Advisory Council, and The Greater Washington Health Underwriters.

A native of Maryland, Stephanie earned a bachelor’s degree in marketing from the University of Maryland in 1986.

Scott and Stephanie have been married for 20 years and have two children.

For more information about Golden & Cohen, visit www.golden-cohen.com. You can reach Scott Golden by email at scott@golden-cohen.com and Stephanie at Stephanie@golden-cohen.com.