WHETHER YOU HAVE insurance through
Medicare, or through your job, or you purchased it
on your own, you could receive unexpected medical
bills—bills you thought were covered. Experts point
to the way insurers price products, organize provider networks and interact with noncontracted
physicians as the culprit. Here are some things you
need to know to avoid surprise bills.
Understand the terms of your policy. Know
the basic terms of your policy in order to understand what you may owe and why. Terms include:
In-network provider: A doctor, hospital or
health-care facility that has an agreement or contract with your insurance company and provides
services to plan members for negotiated rates.
Out-of-network provider: A provider who is not
affiliated with your insurance company. In many
cases, an insurance company will pay less or not pay
anything for services received from an out-of-network provider.
Deductible: The amount of money you have to
pay out of pocket each calendar year before your
insurance will start paying.
Co-pay or co-payment: A flat fee you pay to a
Co-insurance: The percentage of charges you pay
to the medical provider after your deductible has been
met and your insurance has started paying claims.
Before you have a procedure. Ask your surgeon for a complete list of doctors and facilities that
will be used. Call your insurance company to discuss your plan and determine if those doctors and
facilities are in-network. If it is not possible to do
your procedure completely in-network, contact the
out-of-network providers and clarify the balance
you will be responsible for so you can eliminate the
surprise of a post-op bill.
If you get an unexpected bill, talk to your insurance company and the provider. Some providers may
accept the insurance payment as payment in full, or
the insurer and the out-of-network provider may
negotiate a fee and decrease the balance you owe.
If you have a plan that you bought through a state
or federal marketplace, contact your state health
insurance department. Some states have rules limiting
how much you have to pay for out-of-network care.
Prescription sticker shock. Anytime a doctor
writes you a prescription, find out how much the
medication costs, whether it is covered by your insurance and if there is a low-cost generic alternative.
Most private insurance companies can adjust the
list of medications they cover at any time. Medicare
can do that only during the open enrollment period.
If you find out the medication you take is no
longer covered, ask your doctor if you can take a
generic or a similar drug covered by your plan. If
not, ask for an exception from your insurer. You
may also shop around for the best pharmacy price
or get a coupon from the medicine’s manufacturer.
If you have a chronic condition that requires
medication, before you commit to an insurance
plan check if any of the drugs you take are covered.
You will get the lowest out-of-pocket costs when
you buy the coverage plan’s “preferred” generic, or
Tier 1, drugs. A drug that isn’t listed will often have
the highest out-of-pocket cost and may not be cov-
ered by your insurance.
Emergency treatment. Your emergency room
treatment may not be treated as in-network, even if
the ER is at an in-network hospital.
So, it’s important to have an emergency care plan
in place well before you need it. Call your insurer to
discuss your plan and find out which in-network
hospitals in your area employ in-network emergency
room providers. If you get a surprise bill from an
emergency room visit, contact your insurer and the
provider and explain that since it was an emergency
you did not have a choice of providers. The provider
may accept the insurance payment or negotiate a
reasonable fee with your insurance company.
“Balance billing” occurs when an out-of-net-
work provider bills a patient for the difference
between the amount they charge and the amount
insurance pays. Find out if your state’s insurance
department has passed a law that prevents emer-
gency room balance billing. If it has and you get
“balance billed,” you may file a complaint.
If you are on the hook for the balance owed,
double-check numbers by comparing the explana-
tion of benefits from your health insurance provider
with the itemized bill you receive. If you spot discrep-
ancies, address them right away. You can find contact
information for your state on the National Association
of Insurance Commissioners website, naic.org.
For non-life-threatening situations, going to
urgent care may be an option. Ask your insurance
provider for information about co-pays
and potential out-of-pocket costs at a
clinic before you visit.
Appeals. If your health insur-
ance refuses to pay a claim, you
can appeal the decision.
Medical billing advocates may
be able to help you navigate a
difficult billing situation.
You may find the right
advocate for you through
organizations like the National
Association of Healthcare
Advocacy Consultants (nahac.
memberlodge.com) or Alliance of
Claims Assistance Professionals
( claims.org). Fees for medical billing
advocates vary. C
Don’t let charges take you by surprise
David Horowitz is a leading
consumer advocate. David’s
daughter Amanda Horowitz
is the CEO of Fight Back! and
co-founder of FightBack.com.
Questions and answers of the
greatest interest to Costco
members will be used in this
column (with the permission
of the contributor) and will be
posted on fightback.com.
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