What You Owe Your Health Insurance Company—Besides Premiums

A Guide to Your Responsibilities as a Health Plan Member

You're in a partnership with your health plan. You have responsibilities toward it; it has responsibilities toward you. Image © John Lund/Getty Images

It’s easy to assume that all you owe your health insurance company is to make your monthly premium payments on time. Along with that goes the assumption that all your health plan owes you is to pay appropriate claims on time and have enough providers in its provider network that you can get the care you need.

If this is how you feel, I believe you’re wrong on both counts. Your relationship with your health insurance company is more complex than that and requires more from both of you to make it work well.

Here’s what I believe it requires from you.

Be Honest With Your Doctor.

You and your doctor together make a plan of care with the goal of keeping you as healthy as you have the potential to be. In order for that plan to work, your doctor needs to have accurate information about your health, habits, and history.

Here’s an example. You’re on a medication that’s hard on your liver and you’ve been told not to drink. You choose to drink a glass of wine or two each weekend, even though you know you’re not supposed to. You have no intention of giving this habit up.

Be honest with your doctor about that. Explain that you understand you’re not supposed to drink, but that it’s part of your lifestyle and you’re not likely to stop. Your honesty gives your doctor the opportunity to switch you to a different medication or to monitor your liver function more closely.

Being honest is the only way you can get the care that’s truly the best for you.

Since your health plan pays for your care and carries a financial risk if your health goes down the tubes, you owe it to yourself, your doctor, and your health insurer to be honest with your doctor so you get appropriate care.

Get Preventive Care.

By agreeing to insure you, your health plan has accepted a considerable financial risk should your health deteriorate and you need expensive care.

After all, that’s why you have health insurance—you don’t want to accept that entire financial risk yourself.

In exchange for accepting this financial risk, you owe your health insurance company both monthly premium payments and a reasonable good-faith effort to remain healthy or to catch a disease process early when treatment is more likely to be effective and may cost less. For example, high blood pressure pills cost a lot less than treatment for, and rehabilitation after, a stroke.

The Affordable Care Act requires health insurers pay for preventive care without cost-sharing, meaning you don’t have to pay a deductible, copayment, or coinsurance as long as you get your preventive care from an in-network provider. Getting the care recommended by the U.S. Preventive Services Task Force and your primary care physician is part of your responsibility to keep yourself as healthy as possible.

Behave as Though You’re the One Paying the Bills—Because You Are.

Your health insurance company may pay the bulk of your health care bills, but that doesn’t mean it’s OK to be frivolous.

The source of most of the money health insurance companies use to pay your claims is the premiums collected from all of their subscribers. Boiled down, this means we’re all paying for each other’s health care. If we get that care frivolously, we’re wasting money and premiums will go up for everyone.

If your health plan’s website has a cost-comparison function, go online and comparison shop before you have an expensive test or procedure. If your son’s dermatologist prescribes $1,000 pimple medicine for your son’s acne, ask if there’s a less expensive option that can be tried first. If you were paying for that $1,000 zit pill out of your own checking account, you’d surely be looking for a more cost-effective option. Realize that, even though your health plan is writing the check for that pill, ultimately the money is coming from your wallet and mine; use it carefully.

“Wait a minute,” you say.  “My health insurer is a for-profit company. If I save money on health care, it doesn’t keep premiums down. It just increases the company’s profits and gets paid out in shareholder dividends. Why shouldn’t I let my insurer pay for a $1,000 pimple pill? If I’m more frugal, it will just give that $1,000 I saved to some rich shareholder in the form of dividends!”

Yes, for-profit health insurers do make a profit (hopefully). However, they’re required by the Affordable Care Act to spend on health care claims and quality improvement a minimum of 80-85% of the premium-dollars taken in. That only leaves 15-20% for administrative overhead and everything else. If they spend less than 80-85% of premiums on claims and quality improvement, they’re required to give the difference back to health plan subscribers in the form of rebate checks or discounts on premiums. (Learn more about this medical loss ratio requirement of the ACA from the Kaiser Family Foundation.)

Because of the medical loss ratio requirement, the lion’s share of every penny we pay in premiums really does go toward paying for our health care. If we’re not reasonably careful in how we spend those pennies, we’ll all suffer higher premiums. This doesn’t necessarily mean you shouldn’t try to get the most value from your health plan. Instead, it means you should try to be reasonably fiscally responsible while getting care.

Understand How Your Health Plan Works.

Be familiar with your health plan’s provider network and understand the consequences if you choose to get care out-of-network. If your health plan requires you to get pre-authorization before you have an expensive test or procedure, get the pre-authorization. If your health plan requires you to have a primary care physician, get one.

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If Something Doesn’t Seem Right, Tell Your Health Plan.

Your health plan doesn’t allow just any-old-provider into its network because he or she gives it a good discount. It screens providers to make sure they’re qualified to provide the services they’re hired for. It monitors the quality of the services provided.

If you feel as though you’re getting sub-standard care from an in-network provider and the provider hasn’t responded appropriately to your concerns, let your health plan know. It’s sending other patients to that provider, and it’s paying that provider to provide good care. If that’s not what it’s getting in return for its payments, it has the right to know.

Do you suspect a provider is “milking the system,” ordering more tests than necessary as a means of financial gain, or having you come back for repeat visits for no apparent reason other than to bill for more visits? First, discuss this with your provider and clear the air. If that conversation doesn’t end satisfactorily, or if it becomes clear that’s exactly what’s happening, bring your concerns to your health plan.

In my experience, health insurance companies try hard to prevent fraud, waste, and abuse. You benefit from these prevention efforts because it’s ultimately your premium dollars that are being wasted with fraud, waste, and abuse. Help your health plan fight this by telling it if you feel something isn’t right.

Treat Health Plan Employees With Respect.

It’s easy to be upset if you’ve had a claim or pre-authorization request denied. It’s OK to be angry. However, it’s not OK to be abusive. If your frustration makes it difficult for you to behave respectfully toward a particular employee, resist the urge to tell him how stupid and incompetent you think he is, even if that’s how you feel. Instead, explain that you’re frustrated with how the conversation is going and that you’d like to speak with his or her supervisor.

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