Recent headlines say it all. More consumers are facing huge medical bills and shock due to confusion over health insurance coverage.

What people need to understand is they can’t call their doctor’s office and say, “I’m on ABC insurance, am I covered?” and expect a definitive answer on the spot. The rules are constantly changing, and both patients and physicians need to be patient with one another and take steps to ensure the patient is covered.

The “pains” consumers are feeling now reflect the stage we’re going through in the structural transformation of our healthcare system under the Affordable Care Act. While many challenges arose last year, additional changes went into effect January 1, 2016, that will have an impact on patients this year.

So what should you do to help ensure you have health insurance coverage? From my perspective, follow these 7 steps:

1. Be aware that you will need to advocate for yourself. When you think of the term ‘patient advocate,’ most people automatically think of the insurance company or doctor playing that role. However, in today’s insurance environment, things have changed. Now the patient needs to advocate for himself or herself. What we find now is what the patient says and asks for usually matters more than anything else.

2. Tap into resources at your insurance company for help. While you do need to be your own best advocate, you don’t need to go it alone. Most insurance companies have people on staff to help you figure out your insurance coverage and what physicians and specialists you can see. These insurance resources are typically called a patient advocate, patient navigator or customer advocate. You can reach out to these contacts should you have a problem finding a doctor who is in-network or need to request approval to see an out-of-network physician.

3. Scrutinize your current insurance card and read your insurance policy carefully. Most people receive a new health insurance card in January. Before you toss your old card, compare it to the new one to see if anything has changed. For example, has your coverage changed from a PPO to an HMO? Are referrals required to see a specialist? Have co-pays increased? Once you review your insurance card, move onto your insurance policy. Compare last year’s plan to your new plan. A few things to look for include changes to: 


•Co-pays for doctor visits, emergency services, etc

•Preventive services covered

•Prescription drugs covered and co-pays

•Maximum out-of-pocket expenses

•Referral requirements

•Doctors and specialists included in the insurer’s network

•Coverage for using healthcare providers in and out of network

These are just a few areas to review. An insurance company representative can explain your new plan and what changes in coverage to expect.

4. Don’t assume your insurance coverage hasn’t changed. The reality is, even if you didn’t request a change to your insurance policy, your coverage may be different. As insurance companies navigate the new landscape evolving under the ACA, or ObamaCare, many need to make adjustments to their plans and provider lists.

5. Make sure to choose a primary care physician (PCP) who meets your needs. If you don’t choose a PCP, i.e. a family practitioner or internist, your insurance company will choose one for you. Many insurance plans have a restricted network of providers you can see, and not all PCPs can refer you to the specialists you trust.

6. Know that you may need to see your PCP in person, before he or she can give you a referral to see a specialist. According to our Director of Patient Accounting, Matt Chapman, “If you’ve had a long-standing appointment with your specialist, i.e., ophthalmologist, glaucoma specialist, immunologist, cardiologist, diabetes specialist, etc., and your insurance policy changed in the meantime, contact your insurer before you head to the specialist’s office. Keep in mind, the insurer’s list of in-network providers can change at anytime.”You may need a referral from your PCP first, and that specialist may no longer be in the insurance provider’s network. If you’re a Key-Whitman patient, our insurance navigators will ask you a series of questions to determine what services your insurance covers here.

7. Consider opting for healthcare providers that cover a large geographic area. When picking a specialist, it’s usually important to find one that has a large geographic presence. For example, Key-Whitman has locations all over the Metroplex. We have ophthalmologists, eye surgeons and optometrists in Arlington, Dallas, N. Dallas, Mesquite, Plano and Richardson.That avails us to getting into more insurance plans, which means you’ll have an easier time navigating those insurance waters and getting to our most convenient office for the best eye care possible.

During this tumultuous time, it’s important for healthcare providers to be proactive and work with patients to find a solution. We’re here to educate patients about the process and explain that the patient is the best person to advocate for themselves.

You’re also better off choosing a healthcare provider who works hard to be included in as many insurance networks as possible. We want to be there for our patients when they need us. For example, we worked closely with Veterans Affairs (VA), so we could help more vets get quality eye care and cut down wait times. At Key-Whitman we make sure we become approved by as many health insurance providers as possible, so we can be available for all of our patient’s eye care needs.


If you’d like to find out what Key-Whitman Eye Center vision services your insurance covers, call 855.410.8106 to speak with an insurance navigator.