How To Better Understand your Medical Bills
One of the major problems in our society is the complexity of our health insurance industry. Provider contracts are complex and health insurance plans are even more difficult to understand.
I ran medical and disability claims operations all over the world for major insurance companies for most of my career, and have helped friends and family members decipher their complex medical bills and better understand what they really owe if anything.
Here are some basic terms and tips to help you better understand your medical bill:
In network rate- The main benefit of having insurance is to take advantage of the discounted rates your insurance company has negotiated with your service providers (physicians, hospitals etc). These are called “in network” rates. Without this benefit, a provider can charge you whatever they want for their service.. Please ensure your provider is “in network” with your insurance company by calling the insurance company to confirm this prior to your procedure. Many providers will say they take your insurance but you need to ask them “if they are contracted” with your insurance company to ensure you will be receiving the provider’s low rate.
Deductible- The specific amount you must pay before your administrator or insurance company will pay your claim. The lower the deductible, the more your insurance coverage will cost.
I have seen a fair amount of confusion with insurance companies and their understanding of what preventative services are provided to you at no charge and should not be applied to your deductible under the Affordable Care Act (ACA). The most common preventative services are mammograms and colon cancer screening. You can see the entire list of these free services at healthcare.gov/prevent.
Out of pocket yearly maximum — This amount is often higher than your deductible and is the most you will be required to pay each year for your medical expenses. After your deductible is met, you will still rack up charges for co-pays, and you may still owe co-insurance after your deductible is met.
After you have an understanding of the above terms, please also keep these key lessons in mind before you pay your bill.
Lesson # 1
Assume the bill could be wrong — Over 80% of medical bills are wrong and many claims adjusters are thrown into their roles without enough training and have to maneuver between numerous systems to figure out how to pay your provider. Provider contracts are often not updated on time and many insurance companies still have providers on their provider contract rosters that passed away years ago. If you think your bill is wrong, call your insurance company and have them explain the charges. Try to ask for the supervisor as they will be the best person to accurately explain your charges.
Lesson #2
The amount of your bill is negotiable
If you cannot pay your bill, negotiate with your providers. Tell them what you can pay and offer to make monthly payments without interest. If you cannot pay anything, ask them to write off your charges under “Charity Care”. Your provider will send you a form to fill out asking you to list your income and expenses before they agree to write off your charges.
Your providers do not want to negatively impact your credit or send you to collections so try to negotiate with them first.
Lesson #3
Do not pay out of network rates for Anesthesiologists
Most of the time if you have to have surgery or any procedure that puts you to sleep, your provider will use an anesthesiologist that is not part of your insurance network. So it is highly likely you will receive a large bill from an anesthesiologist because they are not in network with your provider. DO NOT PAY THIS BILL
Instead call your insurance company and say you want to appeal this charge because you did not have a choice in picking an in network anesthesiologist when you were put to sleep. Your insurance company will overturn this charge and will then bill you a lower in network rate. Most insurance companies will not tell you that you can appeal this charge.
If you are still struggling to understand your medical plan or bill, consider contacting Patientadvocate.org for assistance.
