January 30 Many Americans who visit the doctor this year are in for some unexpected pain.
A growing number, many of them in employer-sponsored health plans, are enrolled in high-deductible health insurance plans that typically have lower premiums but require consumers to pay thousands of dollars in out-of-pocket expenses before coverage kicks in.
The elderly and the very sick have long battled to have medical procedures and prescriptions covered by private insurers and Medicare. But people in traditional employer-provided plans with $10 or $20 co-pays for medical treatment have been shielded because they do not typically see another bill.
Now it can take almost all year for healthy people to meet a large deductible, which often is two or three times higher than what they are used to paying.
As the high-deductible plans increase in popularity, more people will have to navigate a bill-paying system that's often fraught with errors and confusion.
"It can get overwhelming to consumers," said Victoria Veltri, the Connecticut Healthcare Advocate, who is in charge of the state agency that helps consumers with healthcare coverage issues. In 2012 she fielded hundreds of queries on high-deductible health plans. "It means lots and lots of just straight-up bills because somebody went into the doctor's office for a problem."
MORE HIGH-DEDUCTIBLE PLANS
High-deductible plans have been around for almost a decade, but more individuals and companies are turning to them in an effort to curb rising healthcare costs. Almost 20 percent of U.S. workers are in the plans, up from 13 percent two years ago, according to the Kaiser Family Foundation. While estimates vary, some benefits experts say that could more than double by 2014.
Consumers typically pay lower premiums for the plans, but the deductible can be as high as $3,250 for a single person and $6,450 for a family in 2013.
Paying those upfront costs is supposed to encourage consumers to shop around for comparable, lower-priced care. A 2011 study by the RAND Corporation showed that people in these accounts cut medical spending by an average of 14 percent during the first year after switching.
Another reason the plans are getting more popular is that the president's healthcare reform requires them to include free preventive services. That will be enough for many people, especially young, healthy individuals.
The U.S. Patient Protection and Affordable Care Act, more commonly known as Obamacare, has also introduced new insurance appeals processes that require outsiders to review disputed claims for all insurance plans. The law also created grants for state agencies such as Veltri's to help consumers cope with the changes.
Most often, Veltri said, consumers are calling with questions about why their plans are not covering appointments they believed would be free. People who need help with billing errors and "balance billing," in which doctors bill patients for the portion of their bill that the insurer has not paid, are the next most popular calls.
IN AND OUT OF NETWORK
Disputes can arise from in-network and out-of-network visits. After an in-network high-deductible-plan visit, the doctor sends a bill to the insurance company, which sets the price. If the insurer has a contract with the doctor, the patient is billed for the agreed-upon amount. Charging patients for the unpaid balance is against insurance law in most states.
Meeting the deductible can take a while, even in-network. In recently created health plans, preventive services such as vaccines, well visits for children, annual checkups for adults and cholesterol screenings are free. In family plans with health savings accounts, members pool their qualifying payments and must meet the entire deductible before insurance kicks in.
If the problem is at the insurer and not at the provider, then the insured can appeal to the insurer. For people in insured plans that are paid for by the insurers, the next step is the state insurance regulator.
Harvey Sigelbaum, 75, a retired healthcare executive who lives in New York City, has already had a taste of the hassles ahead for people wrangling with high-deductible plans. Most of his doctors have stopped participating in his private insurance plan over the past decade and no longer deal directly with Medicare, he said. Instead, they bill him directly.
"It's very complicated, and it takes a lot of paperwork," he said. "There was a time the doctor would take care of the claim for you and they would get reimbursed."
Sigelbaum and his wife use an outside group, Health Advocate, to help handle his medical bills and reimbursements.
When there are no pricing agreements, consumers should enlist their insurers to help bring down high bills and straighten out mistakes, according to James Wrynn, a former deputy superintendent in the New York State Financial Services Department who is now a lawyer at Goldberg Segalla.
They may be surprised to find that the insurer can be an ally.
"To an extent the insurance companies are aligned with the patient, even with high-deductibles, because they don't necessarily want to see the patient go through the deductible because then they are on the hook," he said.