Preparing for Cost Uncertainty

“Oh no, that’s going to be a problem for them.”

My wife and I were at the summit of Mt. Washington a few weeks ago, when we spied a family with two small children all of who were wearing bathing suits and wrapped up in towels. The parents had obviously not gotten the memo about the weather up there, even on hot summer days: notoriously cold and windy.

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There is PLENTY of easily available information about Mt. Washington that would have prevented this fail. My wife and I have of course committed similar unforced errors with our kids, as have any parents. We chuckled as we speculated how their conversation went during the drive down.

Since I doubt that it included “this makes me think about our healthcare system”, that’ll be my job.

Weather is predictable. The cost of your care is not. It is in fact MUCH easier to prepare for a day on the northeast’s tallest peak than it is to forecast how much your care will cost. A few examples:

• Prior authorization denials delay the care you need, adding to not only health risks but financial unpredictability.

• You undergo services after a prior authorization was approved. But the language “This is not a guarantee of payment” comes back to bite you and you are facing unexpected bills.

• You require a specialty drug, then discover your employer uses what is called an Alternative Funding Program. The medication your doctor prescribed is not covered.

• Your doctor drops out of network mid-year.

You certainly can’t prepare for everything, but just as I knew to bring a fleece to Mt. Washington, there are a couple of actions I can do to prepare. A few examples:

• Seek out cost estimates for upcoming services and procedures. Ask “what other services may be needed?” or “what other doctors might I see?”after you receive it; health systems can be siloed. Drill in further to see if there’s risk of any of those providers being out-of-network; not everyone in an in-network facility is actually in-network. Get the CPT codes from your provider. Ask both your provider and your health plan for estimates. Dig into discrepancies.

• Get the “evidence of coverage” for your health plan; it’s a long, detailed booklet, not a five page summary. Use AI to upload the document and ask questions relevant to your care.

• Ask your providers if facility fees will be included for certain services and, if so, can it be performed in an office setting.

• Stay on top of your medical providers for prior authorization requests. Do they know the criteria? Find out the criteria yourself anyway. Stay on top for referrals, too; faxes disappear when your specialist and PCP are not in the same system

• Stay on top of deadlines in case you need to appeal.

• If you are receiving out-of-network care and being reimbursed, ensure the provider’s bill they give for your submission accurately reflects what they have charged you.

Nobody has the magic bullets but being aware and informed is the starting point. Reach out to me or another professional health advocate if you need assistance.