What You Need to Know About Health Insurance Part 8

Note: This is Part 8 of an 8 part series that is also being published in the Chester County Press.

“HMO, PPO HDHP or POS, It Really Doesn’t Matter”

When I first became aware of how easy it is for health insurance to deny coverage and care, the HMO was the dominant plan in the country. Today, the HMO has dwindled to something under 20% of the market and the PPO is the more dominant plan. However, the HDHP is coming on fast and there are a number of other new and clever acronyms in the pipeline. So, what does all this change mean? What does it mean for you and me in terms of the care and coverage we can expect and, more importantly, are owed from our changing health insurance?

 Fortunately, the answer is simple. Our plan’s choice of an acronym has essentially nothing to do with what we are owed. That’s because all the different plans operate off the very same Provider Agreement, i.e., an Agreement that defines every element of the care, coverage and payment we are owed. So what is changing? There has to be something given the effort of the insurance industry to separate these plans.

Fortunately, the answer is once again quite simple. It’s the insurance industry walking further and further away from what they have to pay for the care and coverage we need and are owed. And, just as long as they keep their Provider Agreements a deep dark secret, you and I never realize that our insurer is simply transferring the cost of our healthcare to their in-network providers. For, while our plan may have a contractual right to deny payment essentially any time they choose for insurance purposes, their in-network providers have a similarly clear contractual obligation to provide denied coverage free of charge.

 In short, our plan’s retreat from what they pay for our healthcare simply transfers the cost of the care to the provider. But then who knows? Which means you and I get stuck with the bill. A win-win for everyone but us. Our plan gets to pay as little they want while their in-network providers get to ignore their contractual obligation to provide denied care and coverage for free. Unless, of course, you and I know enough to speak up.  

 We began this series of articles by stressing that the laws and contracts that guaranteed our parents the best possible healthcare and coverage haven’t changed. You and I just have to know how to apply them to get what we are owed. Consequently, we have come full circle and will end the series here.

 In closing, let me stress that any and all different opinions on what has been stated in the eight articles is welcome. The goal has always been to improve the understanding of health insurance to where each of us can more effectively pursue what we are owed from our healthcare plan. And, in so doing, make the entire healthcare system more fair and transparent.

See Other Articles in the Series