Dealing with health insurance can be daunting at best and downright frustrating at worse! Because of this, many patients who are seeking joint replacement or spine surgery take advantage of the Texas Health Spine & Orthopedic Center patient navigator 

Because of this confusion related to health insurance benefits, many healthcare organizations have highly-trained experts in this subject. The Texas Health Spine and Orthopedic Center works with two award-winning hospitals, Texas Health Center for Diagnostics & Surgery and Texas Health Presbyterian Plano.  Yesenia Gonzalez is the Director of Business Services for Texas Health Center for Diagnostics and Surgery and every day she helps patients find their way through the labyrinth of health insurance. Today we got the chance to sit down with her to get 3 insurance tips.

Why is Understanding Health Insurance Challenging for Many Patients?

“The terms are also sometimes difficult to understand. For example, some patients do not understand what is meant by a ‘deductible’ or ‘co-pay’ or ‘out-of-pocket expenses.’ Plus, in many cases, patients will transition from regular health insurance to programs such as the federally-subsidized program – Medicare. This program has its own set of services that are covered and offer the potential for supplemental care for patients.

“There are so many variations that many people are justifiably confused and this can be very intimidating.”

3 Strategies to get More from a Health Insurance Policy

#1 Understand What Kind of Health Insurance Plan You Have

“This is the fundamental requirement for getting the most from any insurance plan,” Gonzalez said. “Some plans might be defined as PPO or EPO and these acronyms define the type of network the patient is in. Since not all physicians and hospitals are in all networks, the patient must understand which are in their network.

“If a doctor is in the patient’s network, there will be less out-of-pocket fees for healthcare services that are rendered. Conversely, if the patient wants to use a physician that is out of their network, the patient will not get the best (most economical) benefits.

“Another variation of services and fees occurs if the patient is covered by an HMO. With this type of plan the primary care provider must refer the patient to the appropriate specialist to qualify for benefits. There is no primary care provider referral required if the plan is a PPO or EPO.

“It is important for the patient to be an informed consumer by knowing what doctors, hospitals and medical service providers such as radiologists are in his or her network. This will ensure that the patient receives the full benefit offered by their plan and make the cost of care much more economical.

#2 Know the Fee Schedule

“The second most important patient strategy involves understanding his or her deductible, co-pay and maximum out-of-pocket expenses,” Gonzalez said. “If someone is using services that are ‘in-network,’ a deductible is the amount of fees for services that must be paid before the insurance coverage begins payment.

“On the other hand, a ‘co-pay’ is a set fee that is always paid up-front, before services are delivered. ‘Out-of-pocket’ expenses are those that represent a predetermined percentage that the patient pays, versus the insurance company. When the maximum out-of-pocket expenses are reached, the insurance company pays 100 percent of the remaining expenses.”

#3 Be Aware of Any Restrictions

“In helping our patients navigate their healthcare benefits, I often notice that patients are not aware of the restrictions that they have on their insurance coverage,” Gonzalez said. “Some policies are highly restricted and will only pay for a certain amount of physician fees or other medical services.

“I was helping a patient last week and, unbeknownst to him, his policy only covered two radiology visits. Unfortunately, he was going to need several scans and, because of the restrictions on his policy, he was going to be responsible for the other scans.

“Many patients mistakenly believe that they are only going to be needing coverage for physician visits and they purchase insurance accordingly. This can be an expensive mistake. The best patient strategy for choosing the type of insurance and restrictions is to look at his or her medical history over the past several years. If their history suggests multiple medical procedures, physician visits or other service, their insurance coverage should reflect this.”

One of the best ways to get the most out of your health insurance is to take advantage of preventive care coverage. Some preventive care is 100 percent covered. In many cases, preventive care can help a patient avoid what might turn into a chronic condition and save thousands of dollars in future care.

The patient navigators at Texas Health Spine & Orthopedic Center are trained to take the guesswork and anxiety out of finding a physician for such procedures as joint replacement, spine surgery and other services. This includes helping match patients to physicians in the patient’s network.

Physicians who are members of the referral program practice independently and are not employees or agents of Texas Health Spine & Orthopedic Center.

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