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Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
Information about all aspects of health care from choosing a doctor and treatment, staying safe in a hospital, to end of life care. Includes how to obtain, choose and maximize health insurance policies.
Answers to your practical questions such as how to travel safely despite your health condition, how to avoid getting infected by a pet, and what to say or not say to an insurance company.


The following guidelines can help maximize use of a PPO type health insurance policy. For information about each guideline, see the other sections of this article:

  • Keep your i.d. card with you in your wallet or purse.
  • Use in network doctors and other health care providers as much as possible.
  • If you want to use out of net work doctors and other health care providers, learn how to minimize the amount you have to pay.
  • Make sure you don't inadvertenly use out of network providers. For example, If you agree to surgery, make sure all members of the surgical team are part of your provider's network.
  • If your insurer has a case manager who helps coordinate care, consider him or her a resource for information and guidance. Try to make friends.

  • Keep track of out-of-pocket medical expenses.
  • Avoid paying money in excess of Usual, Customary and Reasonable.
  • Be an informed consumer when purchasing drugs, tests or treatments.
  • Stay on top of insurance company reimbursements.
  • If you have a choice, balance premiums, deductibles, co-insurance, stop loss, lifetime maximum and benefits.
  • Examine discounts for healthy living.
  • If you smoke, quit.
  • If you need an experimental treatment, work with your doctor. You may be able to get it covered by the insurance company.
  • Don't accept a "no" from the insurance company. Appeal. Appeal. Appeal.
  • Choose doctors and specialists with care. Learn how to maximize limited time with them.
  • If your plan has mental health benefits, take advantage of the benefit. You don't have to continue if it isn't helpful.
  • Learn how to keep your doctor if you change plans.
  • Keep in mind that insurance policies are not set in stone. You can negotiate benefits - particularly if you can show what you need will save the insurance company money.

Keep Track Of Out-Of-Pocket Medical Expenses

If your health insurance has a "stop loss" clause keep track of your expenditures so you don't spend more than you have to. Find out from the customer service representative at your insurance company what proof is needed to verify expenditures.

Even if your health insurance doesn't have a stop loss clause,you may be able to deduct the expenses on your tax return.

To Learn More

More Information

Medical Deductions

Keep Your I.D. Card With You In Your Wallet Or Purse

Your i.d. card identifies you as insured. It may also state the amount of your deductible, co-pay and/or co-insurance.

The card likely also includes an 800 number in case you need to speak with your insurer.

You'll need the information each time you see a new health care provider. It will also be available in case of emergencies.

Use In-Network Doctors And Other Health Care Providers As Much As Possible

In network providers cost you less money than out-of-network providers.

Consider using out-of-network doctors when you cannot find an in-network doctor with the experience and quality you need. If the doctor recommends tests or treatments, look to see if they can be provided by in-network providers.

If You Have A Choice, Balance Premiums, Deductibles, Co-Insurance, Stop Loss And Benefits

If you have a choice about features of your policy, it's not easy to foresee how to reach the best balance of premium amount with benefits, and amount of deductible, co-insurance and stop loss.

  • Increasing the amount of the annual deductible
  • Increasing the amount you pay as co-insurance
  • Increasing the annual stop loss
  • Decreasing the benefits

If you think about insurance as a way to pay for unacceptable medical expenses, then it becomes clear that saving dollars now to decrease a lifetime maximum becomes really risky.

With a history of a life changing condition, it seems likely that you will incur a basic amount of health care expense each year. You can pay an insurance company to cover those costs. However, trading dollars with an insurance company is expensive. If you pay the medical costs directly, it only costs you $1.00. On the other hand, if you want the insurance company to pay, it will cost you $1.00 plus money to cover the insurance company's overhead, administrative costs, and profit.

The amount of co-insurance that works best for you relates to the amount of the stop loss, which in turn depends on the amount of money that becomes an unacceptable risk to you.

The balance becomes even more difficult if you are part of a unit with a spouse/significant other and/or children.

An experienced insurance broker or financial planner can help you figure out the balance for your life.

Minimize Out Of Network Costs. For example, if You Agree To Surgery, Make Sure All Members Of Your Surgical Team Are Part Of Your PPO.

If you want to go out of network for medical care, there are steps to take to minimize the amount you have to pay.

For example, it is not unusual for a surgeon to be part of a network, but not other members of the team such as the anesthesiologist. Check with the surgeon or with his or her office manager before surgery to make sure that all members of the surgical team are part of your PPO. If they're not, you may be billed separately for their services.

If you unknowingly have team members that are not part of your PPO, and the insurer refuses to pay, appeal.

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Negotiate Fees With Out-Of-Network Health Care Providers

Studies show that the success rate is high enough that it is worth negotiating fees with a health care provider. It may be uncomfortable the first few doctors you ask, but what do you have to lose?

Consider the following:

  • Ask out-of-network providers before a service if provided if he or she will accept the in-network fee for services or accept what Medicare pays. To find out what Medicare pays for the procedure, see offsite link. Then look for physician's fee schedule.
  • Keep in mind that the American Medical Association says doctors have an obligation to compassionately consider the patient's ability to pay.
  • Most doctors have different fee schedules for the same service depending on who is paying for the service. 

Avoid Paying Money In Excess Of Usual, Customary And Reasonable

An insurer will not pay medical expense above Usual, Customary and Reasonable (UCR) for your geographic area. To get an idea of how this could affect you: If a bill is $1,000, the UCR for that procedure is $800, and your co-insurance is 80%: you will have to pay $160 for the co-insurance feature (20% of $800) plus $200 (the difference between the amount of the bill and UCR.)

The company that gathers data that is used in UCR does not make the numbers available to the general public. Even if it did, each company then applies its own formula to the base data.

If you are concerned that your out-of-network doctor or other health care provider may charge more than UCR, contact your insurance company prior to incurring the expense. Ask how much UCR is for the appointment, test or treatment.

If you and the insurance company disagree, see Arguments To Use Against An Insurer's Denial Of A Health Claim

Also consider speaking with your doctor about lowering his or her fee. Studies show that people who negotiate fees with doctors are successful at least 50% of the time. To find out what Medicare pays for the procedure, see offsite link, look for physician's fee schedule.

Think Of Case Managers As A Resource

From an insurance company point of view, case managers help coordinate your medical care.

From a patient's point of view, case managers can also:

  • Turn a "no" into a "yes" if your insurer refuses to authorize medical care you need.
  • Help make treatment decisions.
  • Provide information about what doctors elsewhere in the country are doing to help treat your condition.

To Learn More

More Information

Case Managers

Stay On Top Of Insurance Company Reimbursements

Today, most doctors and other providers submit bills directly to the insurance company on the patient's behalf, receive the payment directly, and then bill the patient for the difference between the total bill and the amount received from the insurer. While this practice spares you the up-front hassle of paying the bill and waiting for reimbursement, you still have to keep track of payments and amounts due from the insurance company.

To learn more about bills and indemnity insurance, see: Health Insurance Claims When You Pay Part Of The Bill.

For an easy system with which to keep organized, see: Keeping Track Of Your Claims For Medical Bills: A Simple Method

Be An Informed Consumer When Purchasing Drugs, Tests Or Treatments.

If your insurer has a formulary listing approved drugs, ask for drugs that are on the formulary. If there are different tiers of payments depending on whether the drug is branded or generic, ask if an alternative that will cost you less money is available.

When purchasing drugs, balance cost with the other factors that are important to you.

When a doctor suggests a test or treatment, check around for a balance of the lowest price and quality. While test facilities may not be as used to being asked about price, that should not stop you from becoming an informed consumer.

If You Smoke, Quit.

Premiums for non-smokers are lower than premiums for smokers. It may take a while before the company will reduce your premium.

If your plan has high out of pocket costs, see if you can set up a Flexible Spending Account or a Health Savings Account.

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If You Need An Off Label Or Experimental Treatment, Work With Your Doctor To Get Coverage

Insurance companies do not generally pay for experimental treatments. If a treatment you desire could be considered "experimental," work with your doctor to create the strongest argument as to why it's in the insurance provider's interest to pay for it. Get agreement before you take the treatment, or be prepared to pay the entire bill yourself. Perhaps you can find a treatment for free through a clinical trial or from a pharmaceutical company. 

For more information, see:

Don't Accept A "No" From The Insurance Company.

Fight for a "yes." Studies show that persistence pays off.

Follow the insurance company's appeal process. Pay close attention to the dates set by the insurance company by which various actions must be taken.

Once you have exhausted the company's internal appeals, appeal externally if you have that right under your policy or the law of your state. (You can learn about the law of your state from your Insurance Department. Contact information is at offsite link. For policies issued on or after September 23, 2010: thanks to Health Reform 2010, you have the right to an external appeal to an independent reviewer.

To learn about time tested arguments to use, see Arguments To Use Against An Insurer's Denial Of A Health Claim.

Get help for the fight if you need to. Consider:

  • Getting the help of an experienced insurance attorney.
  • Using all sources of influence. For example, if you have your insurance through your employer, ask the person at the company who deals with insurance matters to speak with the insurance company.
  • Speak with your disease specific nonprofit organization. Perhaps they have information that could be useful.
  • Consider applying public pressure via television, radio, newspapers and/or the internet.

Ultimately you can complain to the state insurance department. It supervises all insurance companies which sell insurance in your state. You can find the contact information for your insurance department at offsite link.

You can also start a civil action in the courts.

How To Choose And Maximize Use Of Doctors And Specialists

Ideally, everyone with a serious health condition should have both a primary care doctor to take care of your overall health, and a specialist who is experienced in your condition.

Studies show that time with most doctors is very limited. There are time honed tips to maximize time with a doctor.

Take Advantage Of Your Plan's Mental Health Benefits

Your mental health is as important as your physical health. It can be argued to be even more important in the sense that it is your mental health that helps drive your obtaining the best medical care and adhering to ongoing drug schedules.

A mental health provider can help keep depression and anxiety in check.

Also, if you decide you want to stop work and go onto disability, mental health can be part of a disability determination. In fact, a mental condition such as depression can in itself be considered to be a disabling condition.

To learn how to choose a  mental health therapist, click here.

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How To Keep Your Doctor When You Change Health Plans

Ask your doctor if he or she will join the new plan.

If the doctor will join the new plan, you're set. If not, find out why. The doctor's reason(s) may give you insight into your new plan.

See if the plan has a provision about "continuity of care" under which you have a right to continue to see your doctor for a period of time -- such as ninety (90) days -- or until the doctor certifies it is safe to transfer you to a new doctor.

Check your state law. Even though there is nothing stated in your policy, you may have the right to stay with an out-of-plan doctor, at least for a period of time. To learn about the law in your state, offsite link. To find the contact information for your state's insurance department, see: offsite link

If there is no right to continue to see your doctor, decide whether it is worth it to you to pay the additional money required to see a doctor who does not participate with your PPO insurance plan. It may be worthwhile for a short period of time (say during treatment.) Ask the doctor to order tests and treatments through in-network doctors.

Insurance Policies Are Not Set In Stone.

Keep in mind that insurance policies are not set in stone. You can negotiate.

If you can show that what you want is reasonable, medically necessary, and can save the the insurer money, you have a chance of getting what you want. Speak with a person in authority who can make a decision. If you have a case manager, she or he can help. Also consider bringing in someone to negotiate for you.