Medical insurance -How To Decipher your complex Medical Bills

Whenever I wanted to learn something new and complex like “excel”, I always picked up books with the word “Dummies” in the title as I found these books often presented complex information in a very easy to understand fashion. However when trying to find out how to decipher your medical bills, I do not think this type of book exists due to the complexity of the medical insurance industry.

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 through some basic terms and tips. I have presented these here.

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 potentially charge you a zillion dollars “ out of network rate” for cleaning your teeth ( which some do). Many insurance companies are starting to negotiate very low rates with providers which they say also offer better quality. They refer to these contracts as “narrow network” contracts.

I am not sure the quality is better with providers who have agreed to take less money for their services. Please ensure your provider is “in network” with your insurance company. 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 due to the the Affordable Care Act( Obamacare). 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.

I recently had a mammogram and had to explain to the person in the Philippines that handled my claim that this service was free after receiving a $300 bill for this service.

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 — Many claims adjusters are thrust 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 may be 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 or Labs

Most of the time if you have to have surgery, your provider will use an anesthesiologist that is not part of your insurance network. If you are having a procedure requiring anesthesia, it is highly likely you will be charged an exorbitant “out of network” rate for this service. Most if not all insurance companies will provide you an in network rate if you appeal this charge( they do not advertise this though). As they realize you had no choice in picking the anesthesiologist when you were asleep.

This is also true if your provider sends your specimen to a lab. Ensure they send any test results or tissue samples to labs that are in your network. If they do not, you can appeal this charge too. Your provider is responsible for using in network laboratories but they do not always have current information on what labs your insurance companies have negotiated in network rates