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Start-of-the-Year Insurance checklist

By Martine G. Brousse

"The Medical Bill Whisperer... and insurance stuff too"

Patient Advocate, Certified Mediator

AdvimedPro


November 22, 2023



It is almost a New Year.

Should you do anything if you have a new plan or new insurance company? What important steps you should take in late December or early January?

Yes and let’s make a checklist!


A. Get the documents


1. Insurance card

· Try and get your new insurance card or at least ID#, group# and insurance name to avoid delayed care or billing issues in January. HR or your broker should have that information before 12/31.

· Communicate this info to the physicians you will expect to see in the new year, and don’t forget your pharmacy!

2. Try and get a copy of your new insurance policy or summary of benefits (see #B)


B. Check the details


· What is your and your family’s deductible (what you pay first), co-insurance (the % your insurance pays after your deductible is met) and your maximum liability (what you must pay before your insurance pays 100% of the allowance)

· What are the set Copay amounts for a Dr, specialist and ER visits?


2. Specific services

· What services do you anticipate to continue having or need? Are they a covered benefit? Does your child’s speech therapy have a limit on the number of visits per year? How about mental health sessions?

· Confirm that the present Rx you need are on the new plan’s formulary. If not, your Dr will either have to find an alternative or file a special request for an exception to the formulary


C. Get a (new) PCP


1. The advantages:

· A PCP is the hub for all medical records, facilitating communication between providers and minimizing duplicate tests or procedures

· The PCP can handle most basic care you and your family require, and can refer you to specialists whenever necessary


2. HMO members:

· You are required to have one as this PCP will issue referrals for every service, care or Rx you will need, especially visits to specialists or procedures.


D. Continuation of Care


1. It is your right to:

· Have ongoing treatment or services continue and be paid by your new plan even if that provider is not within this new network

· Have those services previously paid at the In Network be covered at the same higher rate even if the provider is now Out of Network

· Ask that a current authorization is transferred to your new insurance/plan whether services are ongoing or about to start

· Continue receiving a Rx prescription that cannot be switched to an alternative or generic version because of health concerns (allergy, bad interaction to other Rx, previous failed trial etc)


2. BUT:

· Your care should be transferred to a In Network provider or facility as soon as you are stable, or your treatment ends (or your baby is born)

· Transferring your care now would be detrimental or hazardous to your health (i.e. chemotherapy, acute care in a hospital, serious/severe chronic or mental condition)

· Your new plan must cover the service unless an exception granted

· Transfer of an authorization for future services can be denied if a comparable In Network provider is available.



If your current physician(s) do not contract or accept your new insurance plan, you will be considered a self-pay patient, and expected to pay up the full amount billed.

You can locate In Network providers by contacting the new insurance or using their online “find a provider” search tool.


F. Create an online account with your new insurance

Online portals are great for resources, information, communication and education.

You can:

· Locate in network providers

· Audit new EOBs


Start of the year insurance checklist
Start of the year insurance checklist

· Obtain benefits and coverage details

· Use the message center for general questions

· Save time with the “upload claims” and “file an appeal” tools

· Download a copy of your card

· Check authorization status

· Keep track of your met share of cost

· Consult the health library

· Contact a RN for symptom questions or medical concerns

· Compare prices and ratings between providers


G. Get help


1. HR and insurance reps can give you ID info, coverage documents and answer/resolve eligibility questions

2. Be patient! Systems and Departments are usually overwhelmed the first couple of weeks in January, as the flux of departing and incoming members must be managed in a very short amount of time

3. Make sure the office or billing people have updated their filed and are billing the correct insurance/plan to avoid denials and delays in payment (and bills to you!)


In conclusion: The end of the year and early January are crazy time for HR personnel and insurance representatives. Although expected, you can counter a lot of stress and potential errors or delays by getting as much information and documentation as early as you can, and perusing it for the most important aspects.



Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

(424) 999 4705 - F (424) 226 1330

@martine brousse 2023 @ the medical bill whisperer 2023

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