Does it contain surprises?

Who can you turn to?

What to do next?

First, we should admit that all medical care and treatment is expensive and is usually unplanned. It is the main reason for taking health insurance cover. Nevertheless, most insurances leave us with surprise medical bills which are not covered, are probably unexpected, and with costs incurred in traumatic circumstances which may not be affordable.

Secondly, there may be errors in the billing, e.g. for care or medical services you did not receive or medications you did not take.

Lastly, it is possible that there are misunderstandings or misinterpretation of the terms of your insurance.

Let us start with the insurance coverage,

Medical care is expensive especially Emergency Room cost and usually comes out of the blue. That is why we take out insurance, to spread the cost of medical bills and, if possible, share the risk of surprise medical bills.

There is plenty written on the scope and flexibility of the plans available on the marketplace.

Here are some of the main terms: –

  • In-Network – all insurers have a network of providers, e.g. doctors, urgent care providers, hospitals with whom they have negotiated favorable terms.
  • Out of network – providers who do not have a contract with your insurer. There is no discounted rate. You may be held responsible for the full cost of the service provided.  You will be billed directly
    • In an emergency, you may not have a choice of provider, either for transport, treatment or medical care.  If possible, you should choose an In-Network provider, even then it is possible that you will be treated by a surgeon, consultant or anesthetist who is Out of network and may bill you separately. A surprise medical bill!
  • Premium – this is the monthly amount you pay regardless of whether you use the service or not. The premium entitles you to certain preventative services, tests and childcare free of charge
    • Generally, the premium will increase with age, the level of coverage (the type of network) and the amount of your ‘deductible’
  • Deductible – The amount you pay before your insurance takes effect
    •  If you agree a high ‘deductible’ your premium will be lower
  • Co-insurance – the share of the cost (a %age) for the service provided. Note: You will be billed directly based on the discounted price agreed with your insurer
  • Co-Pay – a fixed amount you pay (out of pocket) usually at the point of provision of a service or medication (prescription)

Medical care is expensive especially Emergency Room cost and usually comes out of the blue. That is why we take out insurance, to spread the cost of medical bills and, if possible, share the risk of surprise medical bills.

Read how to minimize emergency room cost.

Perhaps the best way to avoid some the problems caused by the complexities of medical bills is to make sure that you have the medical insurance policy that best suits your needs.  Between now and the period of ‘open insurance’ (November 1st to December 15th), or any other ‘special enrollment period’ to which you may be entitled, you have the opportunity to review your history of medical expense and consider your best options for the future.

The Heath insurance exchanges Federal, State and Private can help navigate the complexities of health insurance to arrive at solutions that optimize your outlay and minimize YOUR risks. 

Beginning with the 2020 open enrollment (NOW) all Health Exchanges are required to display a five-star Quality Rating System (QRS)

The QRS is based on three categories and an overall rating

  • Medical care
  • Member experience
  • Plan administration
  • Overall rating

The Quality Rating System, together with interactive guidance from Exchanges, should empower members in their choice of insurer and encourage insurance companies to raise their standards.

Billing errors

Among the millions of bills sent out each year by health providers and insurers, there are bound to be some errors. Some will be clerical, some due to misinformation or misunderstanding.

For these reasons, it is important to keep records (including telephone conversations) to support your claims either that you have been incorrectly billed or that amounts claimed are covered by your insurance.

  • Insurance policies are notoriously complex legal documents couched in terms designed to cover all circumstances. Insurance companies are obliged to provide a straightforward explanation of benefits (EoB) which should be itemized and make clear which items are, or are not, covered by your policy
  • Insist that your provider, usually a hospital, provides you with an itemized bill. This is a legal obligation. Compare this with your EoB

In any case, the dispute with your provider any procedure or service you did not receive. Do not hesitate to talk to the hospital or your Doctor; they cannot charge you for legitimately requesting information.

As soon as you have an itemized bill and if you have been billed for services which you did not receive, you should write disputing the charges. It is also possible that you received services which were incorrectly coded and might otherwise have been covered by your insurance.

DO’s and DON’Ts

DO

  • Make sure the charges are accurate
    • Check with your insurer who is responsible
  • Offer to pay the amount you agree is owing
    • If you cannot pay this amount in full, work out an interest-free payment plan
  • Ask for a discount if you make a payment in full of any undisputed amount.  Make no settlement without written terms of the agreement
  • Apply for financial assistance: It may need a great deal of paperwork but most hospitals (providers) have systems that recognize the value of compromise.

DON’T

  • Ignore your bills.  They will be sent to ‘collections’. Keep talking!
    •  While you are in constructive negotiations your credit score should not be affected.
  • Use a credit card to pay off your medical bills You will pay a far greater rate of interest and risk losing your power to negotiate with your ‘creditors’.

Nobody goes to court expecting to lose!

If you are confident that you are being treated unfairly

  • Talk first to your insurer and your health insurance exchange

Consider talking to a Medical Billing Advocate. They will take on the administration of your dispute. They may have local expertise, they may offer a no-win, no fee arrangement.