Tips for Dealing with Limited Health Insurance Coverage

If you are like me you may not have the best insurance coverage.   My husband and I are both self employed and are in NJ.  The most affordable health coverage for us is Horizon Blue Cross Blue Shield – EPO Plus.     Everything else is $1000 or so more a month!    It is not bad coverage (covered everything but $500 of my $60K hospital stay and delivery of my son).    It is great if you need surgery or just need to see a few doctors each year.  The worst part is that it only covers $500 in diagnostic services.  This includes all pathology which is blood work, MRI, mammograms, scans or whatever other testing you need.    Surprisingly if you have out patient surgery and they remove something that has to be tested in a lab you have to pay for that separately with your diagnostic dollars.

Pathology is NOT cheap and these bills usually come very late after you have forgotten about your surgery.   If you are in a situation like me look for a doctor who works in a hospital that does their own pathology and does not send it out to a separate lab.   For people in NJ that is Cooper and NOT Virtua.   You will still have to pay for the overage in coverage (or all of it because you will quickly use your $500 limit) but you will NOT be forced to pay “retail” but will only have to pay what they would charge the insurance company which is a fraction of the billed amount.

I found out the hard way.  I was told that you will have to pay the full amount that they bill the insurance company if the service is not covered by your plan.   I was told that unless I made prior arrangements that I owe the full amount regardless of the fact that the insurance company would have paid them only a fraction of what they were billing me.  After a few big bills I started to ask questions and thankfully switched to a surgeon who works out of Cooper hospital.  I learned that if a hospital does their own testing, blood work, pathology or whatever they will only bill you for what the insurance company would have paid.  The outside labs will not do it that way unless (they say) if you had made prior arrangements with them.   I am not sure how to make prior arrangements with an outside lab.

There are also social workers that can work with the billing department to make the services more affordable.   For example I was advised to have a double MRI done in January which will surely eat my entire $500 in diagnostic coverage.    I am told to get it done through Cooper, get the bill, call the social worker, do some paperwork and then they will try to do some magic with the billing department.    The only thing that concerns me here is what they bill might be?    I figure it could be anywhere from $1k-3K depending on if they can do both sides of the breast at one time.   I think I will make a few calls to find out how they do it, and get an estimate as to how much they charge and how much the insurance company would pay.

I found some cheap ways to get MRIs online but my doctor says that the technician reading them may be sub-par.  That you can have an MRI done but if the person reading it is not good – then it is pointless.  Given this I will not go this route….although it is attractive to just pay for it and not deal with my insurance and all of the unknowns.

I am not sure what I would do with the information from the MRI anyway as I see it only as a way to confirm my situation….a way for me to obtain more peace of mind.   I do not intend to get treatment from my doctor if they suspect something.  I also would be reluctant to get a needle biopsy knowing what I know now (that will be for another blog post).


I hope you have better insurance than I do but if you don’t I hope you found this information helpful.



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