The Costco Connection

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 health-service provider.

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

Medical-bill basics
Don’t let charges take you by surprise

DAVID&AMANDA
HOROWITZ

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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Please note we are not licensed professionals in any field. If you are seeking advice you should consult with your own licensed professional. We do not assume any liability or responsibility for the interpretation, application or accuracy of any information provided.