Understanding Health Insurance

Millions of people now have health insurance because of Obamacare.  But do they understand how to use it?  For many people, even those with a college education, the answer is “no”.

I recently got a call from a client who got health insurance this year.  She was upset at her insurance company because she has been unable to get a referral from her primary care physician (PCP) to see a dermatologist – or that’s how she explained the problem.   I asked Diane a few questions and discovered the problem is not with the insurance company, but with the PCP.

Diane saw the PCP for a skin condition and asked to be referred to a dermatologist.  A month went by and Diane still had no referral.  She says she left two messages for the PCP but got no response.  What this tells me is that somebody in the doctor’s office dropped the ball.  Or maybe they don’t know how to look up specialists in Diane’s HMO plan network.  Or maybe they are too busy – – though setting up referrals is pretty central to the work of a PCP’s office staff.

I told Diane I would make it easy for the PCP to write a referral.  I looked up dermatologists in her plan network (there are lots of them) and got her a name to give to the PCP.  Then, all the PCP (or her staff) has to do is write the dermatologist’s name on the referral form and send it off.

It turns out my own dermatologist is in Diane’s HMO network and I know this doctor’s group can usually get a person in to see a Nurse Practitioner  within a few days.  I gave Diane instructions:

1)  Call the PCP office and talk to someone who sets appointments.  (The number for “referrals” required her to leave a message. She had tried that twice and gotten no response.)

2)  Tell the PCP staff person (politely) that she has left messages and needs to be assured that someone will follow up on her referral request.

3)  Give the PCP staff person the name of the doctor to whom she wants a referral.

4)  Ask (politely) how soon she can expect the referral to be sent to the dermatologist, whose name she  provided.

5)  Once she knows the referral has been sent to the dermatologist, call that office to set an appointment.

A couple of times during our conversation, I had to get Diane back on track because she kept referring back to the insurance company.  She thought the insurance company was the reason she had not gotten a referral.  She did not realize the PCP did not work for the insurance company.

Diane is not my only client who has had issues when it comes to understanding health insurance.

I think insurance companies should send every new customer a short instructional video that explains how to use their health insurance plan.  Health insurance is only good if the customer knows how to use it.  People who have never had health insurance certainly don’t know how it works.  And even people who have had good employer coverage do not know how darn complicated their new, individual health insurance plan is.




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