Saving Some Healthcare Dollars

Working in the health industry has made me privy to a lot of mistakes people can make with regards to their health, mistakes that not only cost them their health, but also a lot of money. With the current economic climate and skyrocketing health and medical insurance, how can you save money on your healthcare?

1. Enroll in Medicare, Medicaid or buy healthcare/medical insurance. Choose your insurer well. Before thousands of you drop your mouths and tell me I must be out of my mind for suggesting this, consider that if anything happened to you and you're not covered by any form of medical insurance, the only place you can go to for your medical care is the emergency room? If you get a 102-degree fever along with other symptoms you know for sure means a "really bad illness" and you don't have medical insurance, the only way you'll ever be able to get treated or medication for your illness is to go to the ER. Unless you're an illegal alien, the ER may not even provide you with enough antibiotics and whatever else is needed to treat your sickness. So you need to be covered in some way so you don't die of whatever it is you've got.

Medicare insurance is for senior citizen Americans age 65 and older. If you are disabled or have kidney disease but are younger than 65, Medicare will still cover you. Medicaid, on the other hand, is administered in some form by the various US states and only covers people with very low incomes and high medical bills. Medicaid takes into account your age, disability (if any), family status, and your total family income into consideration before they qualify you. This means that, if you're falling through the cracks between these 2 government-funded programs, you have to purchase your own medical insurance either by working or asking a member of your family to list you as a beneficiary on their medical insurance policy. (Even then, some insurance providers will not provide coverage to kids or dependents who are over 23 years old, even if they are still full-time students or bumming around.) There are very few clinics around who will take in a person who will not be able to pay for a visit to a doctor. And it's not a matter of money but liability.

2. Familiarize yourself with your insurance plan and coverage. What will your insurance provider pay for? How much is the co-pay for regular office visits? for referrals? for consultations? for out-of-network doctors? ER coverage and deductible? deductible on procedures or surgeries done? Knowing these early by reading your plan brochure will give you a better idea of what to expect and what they will and won't pay when you do get sick.

3. Establish care with a primary care doctor. The best way to keep your health costs down is to make sure you get a primary care physician (PCP) once you're covered by medical insurance. Make sure the doctor is one of the accredited doctors listed in your provider's physician network. Granted, you had to pay maybe 1/3 of your month's salary to get covered in the first place, but once you establish yourself with a PCP, all you need do is pay for co-pays or deductibles and the rest should be easy.

4. At your first visit to the PCP, make sure you apprise him/her with your full medical history. The worst thing you can do is, as Dr. House (i.e., House, MD) is always fond of pointing out, lie to your doctor. Letting your doctor know your full medical history will enable him to make informed decisions with regards to your care as well as make the right referrals to other specialists when you do get sick. Just watch House, MD each week, and you'll find out how patients make their doctors decide on the wrong treatment by not divulging their health information. Besides, the HIPAA Privacy Act guarantees that everything you reveal to your doctor and thenceforth written in your medical records are protected information and can only by seen by the people you authorize (spouse or partner/close family member, insurance provider, other doctors involved in your care) other than a court decree. If you believe your medical information has been compromised, then the HIPAA website will help you with taking the necessary steps in taking corrective action. I have had opportunity to put the HIPAA system to work, and believe me, it does work. They actually acted very fast on my behalf, that the problem I e-mailed them about on a Monday was already resolved by Friday of the same week, with them contacting the medical facility(ies) concerned and bearing down the full weight and authority of the government upon them.

5. Have regular annual physicals and regular followups, the latter as decided by your PCP. This is also known as preventive care. Did you know that some healthcare insurance providers will actually deny you care for a dreadful illness if you have not followed up regularly with your physician? If you don't have medical insurance and have not been following your health status or taking care of yourself, and you're suddenly diagnosed with a dreadful illness that will require thousands of dollars to treat, Medicare or Medicaid can actually deny you coverage until you pay some sort of fee up front? I know it sounds terrible, but that is how it is.* Let me give you an example: my family and I once had medical insurance that specified strict annual exams for everyone covered. For myself, this included an annual gyn exam that covered a routine annual mammogram, depending on your age. At the time I was younger than 40, so the plan will only cover for a mammogram every 5 years, except if I have a family history of breast cancer for which they would require a mammogram every 6 months. If I missed one of the 6-month mammograms, and a year after the last mammogram I was found to have breast cancer, the insurance provider will actually deny coverage for my treatment for that cancer. Their logic is that, with my family history, their plan strictly required that I have a mammogram every 6 months, which would enable my doctor(s) to catch any sign of disease at the earliest possible stage during which time the hope is that it would still be easy to treat. But because I had missed one 6-month mammogram and took it at a one-year interval, they could deny payment for the treatment because the reasoning is that if I had not missed my regular 6-month followup, the disease would have been spotted and been easier to treat, therefore, less expensive to pay. This is another reason why you really have to familiarize yourself with your plan and what it covers as I already mentioned above in no. 2.

Almost all healthcare providers, doctors and insurance companies alike, stress preventive care more than anything else. Some insurers will actually give you discounts to gyms or to attend a regular exercise program, whether it's in the form of dance, yoga, pilates, etc. In addition, they will stress annual physicals that is usually the best way to spot any disease or illness at its earliest stages. Some medical insurers actually give their policyholders the additional incentive of a free annual exam, just to make sure their members do not miss having one. I mean, if it's free, then seriously, you don't have any excuse not to go for it; you've already paid for some of it with your monthly contribution to your plan, so take full advantage of it! At these annual physicals, make sure you ask for and get the works: urinalysis, blood pressure (BP) check, EKG (not annual if you're younger than 40), stool exam, chest x-ray (not annual if you don't have any habits or exposures that may preclude future pulmonary disease later), mammogram (for women), rectal exam (for men's prostates), complete blood work inclusive of a CBC (complete blood count), BMP (basic metabolic panel that checks your enzymes and electrolytes), lipid panel (checks for cholesterol), TSH, and PSA (this last for men). For older people, the bone density or DEXA scan is fast becoming a standard test to check for osteoporosis. Most medical insurers cover 100% of these tests (meaning, again, that they're free) when taken in conjunction with your annual exam.

Each of these tests are now deemed standard by insurance companies as well as doctors, so that for one single co-pay you are actually getting a lot. The urinalysis will tell your doctor if your kidneys are functioning well and whether or not you have infections in your genitourinary area. BPs can give you a clue if you're becoming hypertensive or not. An EKG will determine if your heart is functioning normally for your age. The stool exam detects early forms of cancer as well as any bad pathogens you may have like E. coli, etc. The chest x-ray is particularly important if you're a smoker or have asthma. The mammogram will detect some signs of early breast cancer, while the rectal exam, in conjunction with the PSA and sometimes the urinalysis, can tell you if you're at risk for any prostate infection, BPH, or prostate cancer.

The CBC can tell you if you're anemic or not, have an infection or not. The BMP will tell you if you're liver and kidneys are working properly, as well as tell your doctor if you are about to develop diabetes, while the lipid panel will tell you if you've developed hyperlipidemia (high cholesterol) already. The TSH tests for unusually high or low thyroid-stimulating hormone in your blood that can make you either hypo- or hyperthyroid. Used with other TFTs (thyroid function tests) that checks for free T4 and T3, it is a good indicator of thyroid disease. So in case you're in doubt about whether you should go to the lab with your doctor's blood work script, then I hope what I just wrote about what these blood tests do to help your doctor determine the state of your health will convince you that you should

6. If anything doesn't check out well in your annual exam, and your PCP refers you to a specialist for a further check and/or testing, make sure you have a referral. A referral from your PCP can mean the difference between your paying full price for any tests done by the specialist or just the deductible as specified in your medical coverage plan. When I say specialist, I mean one of those other doctors who specialize in specific areas like cardiology (heart disease), pulmonology (lungs), endocrinology (diabetes, thyroid problems), gastroenterology or GI (stomach), etc. (A PCP usually is someone who "specializes" in internal or general medicine.) Most medical insurances will not pay for a self-referral: this means you going to a doctor's office because you believe yourself to be sick of something that needs a specialist's treatment. When you do have a referral, make sure it is dated before or on the date of your visit and covers any or all treatments and tests related to the problem you are being referred for so your insurance company can pay for all these. Most doctors' offices will fax your referral and then give you a copy so you can go to the specialist's office with it in case the other office "misplaced" the fax (as they usually, if not often, do).

Some insurance companies will not allow back-dated referrals: this means that if you forgot your referral and went ahead to the specialist and get billed for it, even if you go back to your PCP and ask them to back date the referral, your insurer already knows full well you didn't have it at the time of your visit, so unless you didn't sign a waiver, you're stuck with a huge bill that you will now have to negotiate payment for with the specialist. Still other insurance companies will not accept referrals given by a specialist, which means all your referrals should come from your original PCP in the first place. This is all the more reason why you really should establish yourself with a PCP first as mentioned in no. 3 above. Let me give you an example: let's say your PCP referred you to a cardiologist because he found something off in your EKG. The referral that your PCP's office gives you should cover all reasonable services and regular tests that cardiologist's offices usually do to confirm or verify the EKG finding. Let's say the cardiologist thinks you should undergo a special test that's usually an optional treatment -- optional, meaning not everyone goes through that test because there are other alternatives -- and the only reason you're going through it is because he wants to absolutely rule out you don't have what he suspects you have. The referral for this special test should still come for your PCP, not your cardiologist, UNLESS your plan coverage allows you to have the cardiologist make the referral (which is very, very seldom). At the very least, the cardiologist should contact your PCP, or ask you to contact your PCP, to get the referral from them. Otherwise, your insurance will not pay for the test. And believe me, when specialists refer you for special tests, that usually means the test will cost somewhere in the vicinity of at least $1,000.

7. Do not insist on brand medications if there are generic alternatives available, UNLESS your health is going to suffer severely if you take the generic. Due to the high cost of medicines, medical insurers have varying prescription plans that will usually have several tiers of medication coverage. The one that costs little to you are those on the plan's list of approved medications, usually including generics and other common prescription medications. Almost all insurers will not cover OTC (over-the-counter) meds, so the only way you can get paid back for those is if you have a flex plan at work that can refund you that money. Unless your doctors have proven that you do better on branded meds, most insurers will not allow you to get the brand-name medication even if your doctor writes DAW (dispense as written) in that little box. Any medication not on your plan's approved list will require prior authorization ("pre-auth") from your insurance company. Your doctor will receive forms he/she needs to fill out in order to justify why you need the particular med that's not on their list. Moreover, they will usually supply your doctor with a list of similar, approved meds that they strongly suggest he have you try first before even asking for pre-auth for the special med. A good doctor will go over these options with you and tell you which of the meds will have the same effect as the original medication he or you were planning to take. So other than severe allergic reactions to the suggested meds on their list or a poor response to them, no way are you going to get that particular med. Furthermore, if you do have proven allergies to the approved meds on the list, your insurance company will pay for the bulk of the special med, and all you'll end up paying is just co-pay anyway. If you don't have any other reason than because you just want that particular med because you read on the internet it's "the best", then you'll literally have to pay the price for it.

8. Nothing beats a good diet and exercise. Finally, I guess there's nothing that will save more money for you than a good diet and exercise. Let's look at it this way: if you don't care what you eat and you don't exercise at all, one of the first problems you'll be faced with is becoming too heavy for your height (the body-mass index, or BMI, ratio). If this problem becomes uncontrollable, you soon will become obese. When you become obese, you soon become hyperlipidemic (accumulate bad cholesterol in your blood). If you don't take action by trying to control this with lifestyle modifications and changes in your diet, the next thing your doctor will be looking out for is your blood glucose level. Numerous websites and magazines will tell you that obese people are more prone to diabetes. Both hyperlipidemia and diabetes are controlled with medication , and insurance will cover most (if not all) of them. But as you grow older, the lack of good diet and exercise will take its toll because pretty soon you'll be hypertensive (high blood pressure), maybe in your 30s or 40s, by which time there is no way that you can get rid of the numerous meds you have to take for these 3 alone without addressing the root problem: eating a good diet and increasing your activity level. Note that your doctor will also give you advice on diet and exercise when he realizes you are hyperlipidemic, diabetic, and hypertensive. When you reach 50, your bones will start feeling your weight: the strain of it will be giving you either muscle pain or bone pain, particularly in the back (the main support for your skeleton) and the knees (the main supporter of your body). This will give you even more problems as you drive your doctors crazy prescribing meds that will relieve your pain. If you have other habits that affect your health such as smoking, then it will just compound your problem. And so it goes on.

So besides #1-7 above, make sure you are proactive about your health by taking good care of yourself with regular exercise (walking is a good start) and eating a good diet (not so much of the chips, salt-ridden, fatty, and oily food, and more of the fruits, vegetables, as well as 6-8 glasses of water a day). When you see your PCP, ask him/her what they suggest in terms of a good diet and a good exercise regimen. If you are already now concerned about your weight, talk to your doctor about referring you to a nutritionist. Check your health plan now and find out if they will give you discounts or incentives to join an exercise or weight-reducing program. Believe me, the benefits can be tremendous, because if you can put off by several years the time your body succumbs to age and starts having conditions that are "normal" with aging (among them hyperlipidemia, hypertension, and adult-onset diabetes mellitus), then you will have saved several dollars on followups, specialist visits and co-pays, as well as prescription co-pays on meds for conditions that you could start paying for when you're already a senior. Besides that, when you aren't in good health and you apply for a life insurance policy, you will be asked to have a complete and thorough physical, sometimes done by the insurance company's own nurses, doctors, and labs. The poorer your health is, the higher your premiums will be when they approve your application. So in order to actually save money on your healthcare, you have to start by taking care of yourself, then make the most out of your health plan by making wise choices about your health and healthcare providers, and following up and consulting with your doctor about your health.



* It's not as if it's any better off in the Philippines where your employer, who pays for your medical insurance, can actually deny coverage to you for a pre-existing illness that you've had before they hired you. I.e., if you have untreated cancer and you went to work for any company in the Phils., and the illness was discovered in an employment physical, most companies will not cover that illness or any complications arising from it, so you're left to pick up the tab. But then again, the cost of healthcare there is not as prohibitive as it is here.