Is Your Insurance Plan Determining Your Care?

Your insurance company’s coverage guidelines may not align with your needs. A few examples.

June 27, 2021

Do you get your teeth cleaned twice a year? If so, it’s probably because that’s what your dental insurance covers, but biannual cleanings aren’t enough for everyone. A patient with gum disease might benefit from quarterly cleanings, even if they have to pay out of pocket.

It’s important to have the right health insurance, but your insurance company shouldn’t be making your healthcare decisions—that should be between you and your doctor. Instead of asking your doctor what your insurance will cover, ask what course of treatment the doctor recommends. 

Your insurance company’s coverage guidelines may not align with your needs. A few examples:

  • If you need physical therapy after an injury, and your insurance covers two sessions a week, ask the doctor if another weekly session would be beneficial. If so, consider paying for those extra sessions out of pocket.

  • If you think you need a walker for help with stability, but your insurance bases their coverage on how far you can walk, they may say you’re not eligible. Your best option may be to buy a walker yourself (for under $100) so you feel more secure on your feet. 

  • If you’re considering bariatric surgery, but your weight or BMI doesn’t meet your insurance company’s cutoff point for coverage, the surgery may still be a good choice for you. Research the costs instead of letting your insurance company make that decision.

Insurance companies make broad decisions about who qualifies for everything from oxygen to inpatient rehab programs, but they don’t know you and your unique situation.

Focus on Getting the Care You Need

A health advisor can help you identify and overcome barriers to care.   

  1. A health advisor can advocate on your behalf with the insurance company to make sure you get the best possible coverage.  
  2. If you have to pay out of pocket, a health advisor may be able to negotiate a lower fee.
  3. A health advisor will let you know about alternative treatments options that are worth considering.

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