To save on medical costs, ask the right questions, reimbursement director says

Dawn Waller of Hiawatha is responsible for all financial reimbursement for Iowa Eye Center, a Cedar Rapids ophthalmology clinic. The clinic sees 200 patients a day and files claims to more than 1,000 insurance plans, Waller said. She responded to a Gazette solicitation seeking reader experiences in identifying health care costs in advance of treatment.

I would love to talk to you about the challenges we face in providing health care costs to patients prior to a service or procedure.

Most people will call and simply ask how much the procedure costs. This question in itself will not give them the information they need. The cost of a procedure is not a true reflection of what they will likely have to pay out of pocket.

There are so many factors involved in providing an estimate of costs and many times we cannot even start this conversation because we haven't seen the patient. Doctors' fees are based on multiple levels of care depending on patient complaint, history, exam and medical decision-making. It would be like calling a mechanic and saying, “my car won't start, how much will it cost to fix it?” before he's had a chance to take a look.

Another problem we constantly run into is the patient who has decided what services they want based on what their insurance will pay. Some patients want us to use their routine exam benefit for services related to an acute condition because the co-pay is less. We can't do that, it's called insurance fraud.

Some people think that since they were in the doctor's office for their routine exam they should fix or diagnose any problems without having to come back or pay for any future services. This is like taking your car in for an oil change and expecting they will fix the brakes and flush the radiator without any extra time or money.

Another thing consumers need to be aware of is every time you call a physician's office for questions regarding your insurance coverage, or estimates of costs, it increases the overhead of the physician's office. We have to have someone answer the phone, triage the call, take the appropriate action and follow up. We definitely want to help our patients make informed decisions about their care and we are here to help, but it is a Catch 22 when you talk about holding down health care cost.

My best advice to a patient is to make sure you know about your personal insurance coverage. What are your benefits? What type of provider are you seeing? Is he/she your primary care physician or is it a specialist? Do you have to go to network providers or do you have an open-access plan? What are your deductibles, co-pays, co-insurance, and out-of-pocket maximums? If you have a high-deductible plan, are you prepared to pay for all of your health care costs up to that amount?

Remember your costs most likely will be different than those of your co-worker, neighbor or maybe even your spouse. Just because someone works with you does not mean they have the same coverage. Maybe they are covered under their spouse; maybe they didn't choose the same insurance you did; maybe their condition isn't the same as yours even though you both went to the same doctor.

When people call to get estimates they need to be prepared to share current and accurate information about themselves, and understand we will have to do some research so we may not be able to give an instantaneous response.

What is the name, subscriber number and contact information for your insurance? Is this your only coverage or do you have coverage under a spouse or supplemental plan? We then have to contact your insurance company and get information about your coverage. Have you met your deductible? What are your co-pays, co-insurance amounts? We will have to determine what fee schedule that insurance uses and make our calculations.

If there are other providers involved in the care, such as hospital or anesthesia, the patient may need to contact them also to get their estimates because we do not have access to their fees and insurance reimbursements.

I know insurance jargon is like a foreign language, but it is the most important foreign language today's consumer can learn. It is so important to read your benefits manual.

The physician's office is not the place to call to find out what is covered. If you have questions about your eligibility and benefits you need to contact your insurance company. … If you still can't understand what is covered or how to use your insurance, contact your Human Resources Department.

I agree that patients need to be informed about their health care costs, but it needs to start with the patient and insurance company before they call for their appointment or get to the office.