As a consumer, when you seek treatment from a health care provider such as a doctor or hospital, you will generally be asked for your health insurance information. If you have a health plan, the hospital or doctor will routinely contact your health plan to verify whether you are a member as well as the extent of your benefits. Very often, the information received from the plan can mislead the verifier into thinking that you have more benefits than are actually available.
So for example, the health plan will tell the verifier that you have a $2M benefit limit, a $5K deductible and $10K in out-of-pocket liability. At first glance, it would appear that you have $2M in benefits, which would be sufficient for most hospitalizations. However, that $2M sum may pertain to your lifetime benefit maximum, which may be much less now due to your prior hospitalizations and treatments.
To further complicate matters, some health plans have annual and transplant benefit limits, among others, which are often less than the lifetime benefit maximum. For instance, you may have $2M in lifetime benefits, but only $1M in annual benefits. Thus, even though you have $2M in lifetime benefits, the plan’s obligation to you is limited to $1M per year.
Unfortunately, we have seen too many cases where a verifier understands a $2M lifetime benefit maximum – which is factually correct – to mean that the patient has $2M in benefits available to cover a hospitalization. These verifiers are generally ignorant to the fact that prior hospitalizations and treatments can drastically reduce the lifetime benefits leaving perhaps only $50K in remaining benefits. That reduced sum may not be sufficient to cover the current hospitalization and once the patient’s lifetime benefits have been used up, the balance of the hospital’s bill, which may be significant, will likely be assessed as the patient’s responsibility.
Of course, the same type of scenario could occur with other types of health plan benefits, including annual and transplant benefits. For example, the verifier may be told that you have an annual benefit maximum of $1M which is factually correct. However, you may have already used up $950K in annual benefits, leaving only $50K in benefits available for the current hospitalization. Unfortunately, if you don’t have a good verifier who asks the right questions, the health plan does not usually offer up information regarding the amount of benefits that remain available to you and you could be liable for more than you originally thought.
To ensure that you have a sufficient level of benefits to cover your hospitalization, it is important for any verifier to ask the right questions and get the full benefit story from your health plan. We recommend that the verifier obtain from the health plan ALL benefit maximums under a patient’s health plan – lifetime, annual, transplant, etc. In addition, and perhaps more importantly, the verifier needs to obtain from the health plan the amount of the remaining benefits for each benefit category (lifetime, annual, transplant, etc.). It may turn out that you have very little lifetime, annual or transplant benefits remaining, and if you know that ahead of time, you can make other payment arrangements to help cover the cost of your hospitalization and not be shocked by a huge bill after discharge..