Scrutinize The Fine Print in Your HMO Plan
Source: Los Angeles Times
Many Americans can expect to experience a little sicker shock as they begin receiving health insurance bills this year showing that few have satisfied their plan’s annual deductible and could be responsible for a hefty portion of the bill, if not all of it.
That’s especially true for patients who go out of network — that is, use a doctor who doesn’t accept their insurance or is not part of their managed-care plan.
I know this firsthand.
My portion of a bill from an out-of-network physician — for an hourlong checkup that included lab work, an EKG and chest X-ray — recently came to just over $1,000.
Regardless of the amount, all bills should be read carefully.
“Much of a doctor’s bill and insurer’s explanation of benefits can seem indecipherable, and often they are,” says Tom Billet, a senior consultant on healthcare issues in the Stamford, Conn., office of benefits consulting firm Watson Wyatt. “Reviewing the doctor’s bill to be sure they didn’t add in services you didn’t have, and reviewing the insurer’s document to make sure the charges match what’s in the doctor’s bill, could save some people some money.”
In my case, a review of the bill found no blatant mistakes, padded charges or unjust refusals by the insurer. But it did find that the doctor’s office had charged for separate lab tests done with just one blood draw. The insurer flagged and allowed only a bundled test, the fee for which was much lower than the individual tests on the doctor’s bill.
Reviewing medical bills and reimbursement notices — and challenging them if necessary — is crucial. Billet and other consultants offered these suggestions:
Pay attention to the details.
Whether or not you’re insured, the doctor’s office should give you an itemized bill accounting for any professional encounters and tests. Make sure you received all the services for which you were billed.
After breaking a toe several years ago, Billet was told he didn’t need an X-ray because the treatment — taping the toe to its neighbor — is the same regardless of what the films show. But Billet’s bill included an X-ray charge.
Even if you receive the bill in the office — and must pay before leaving — take the time to look it over and fix any mistakes. As Candy Butcher, chief executive of Medical Billing Advocates of America in Salem, Va., notes, getting a refund can be difficult. If the bill is complex, ask to take it home to review before making payment arrangements. If the office balks, ask if paying a small percentage of the bill will suffice.
Get What You Pay For Just as if you were paying for the services of an expensive Austin TX divorce law attorney or for a whole team of Redwood City CA criminal attorneys, you should always ask for proof of what you’ve been asked to pay for. Why would you visit a doctor or an ER for that matter, obtain treatment and promise to pay for it without a written document showing what was done and how much it cots?
Learn the terminology.
Insurers offer glossaries in their handbooks and on their websites explaining such terms as “deductible” and “co-payment/co-insurance.” It’s good to be comfortable with the terms, Billet says, so that you can explain discrepancies or overcharges. For example, people who are used to paying a flat-fee co-payment can be confused if they switch insurers and are now paying co-insurance, or a percentage of the fee. “Understanding the terms helps put you on a more equal footing with the insurance representative when you have your conversation,” Billet says.
Read the remarks.
Insurers include number codes, typically explained at the end of the document, to let you know why they refused a particular charge. Dr. Geni Bennetts, formerly a pediatric oncologist and now a billing advocate based in Napa, says a common reason for refusal may be that a physician simply billed for generic lab tests and that the insurer needs to see specific tests listed, such as “lipid panel” or “complete blood screening” to determine whether the charge is eligible. In those cases, check with your insurer to see how a more detailed breakout would be resubmitted. The doctor’s office may have to redo the numbers before the bill can be resubmitted.
Use customer service.
Don’t hesitate to call your insurer about a charge you think should have been paid, or paid at a higher rate. For example, many insurers now charge a large share of an emergency room bill if there was no actual emergency — sometimes a hard thing to determine at the time.
“If you think you had medical care that was justified but your insurer turns you down, call customer service, but then also ask for a supervisor if you think you’re not being well served,” says Helen Darling, head of the National Business Group on Health, an association that helps large corporations tame high healthcare costs. Other encounters worth an appeal to customer service include an appointment with an out-of-network specialist if the plan’s network did not have someone with the same specialty or an emergency room visit for chest pains that turned out to be gas if the patient had a family history of heart disease.
No satisfaction from customer service? Insurers allow appeals, usually within 90 to 180 days of the date of payment for a denied claim. Check the manual or customer service number to find out how to file an appeal.
Consider a billing advocate.
For particularly expensive bills, such as for a major operation or long hospital stay, for which you paid completely out of pocket or got little reimbursement, billing advocates may be able to go to bat for you. Advocates may charge by the hour or take a percentage — often 20% to 30% — of any money they are able to reclaim from the insurance company. A few firms offer this service free to their employees. More likely, the person who handles insurance at your company can refer you to a billing advocacy firm; so too can a hospital’s patient advocate office.
Deal with doctor’s office.
My biggest blunder: I should have asked the doctor if I could have the lab work done at an in-network lab instead of at his office. Less convenient for sure, but billing specialists say I could have saved $400 or more.
Even if I’d decided to stick with the in-house tests, doctors often will give a discount to patients paying in full, perhaps as high as 35%. In my case, that would have been over $350. Butcher says I likely would not have had to bring it up with the doctor at all; many office managers are authorized to adjust bills for patients. And they’ll often discount a bill even for patients paying in installments.
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My Take: I don’t think I know anyone who actually sits down and reads, let alone scrutinizes their insurance plans’ fine print. I’d rather play the casinos online with my free time because it would take a lot of it to figure out what every word and angle in my HMO handbook from work actually means. I’d have to hire an Austin divorce attorney if I really knew what my husband’s benefits plan outlined, what his deductibles are and what’s left over because he never brings any of the information home.
I like the idea of hiring an advocate to go to bat for you if you think you have a valid claim about a deductable charge on your medical bill. Have you visited an ER for an infection or some kind of minor illness on a weekend when you couldn’t get to a doctor and needed care? It’s rough. Hospitals, ERs in particular, are notorious for making you wait 7 hours in the crowded waiting room all night, dragging you in to see a doctor at 5 a.m. when you’re so tired you’ll agree to just about anything. Then, you get the bill, which always includes a lot of mumbo jumbo about tests and CBC counts and you have no idea what’s covered and what you’ll have to pay for until your insurance company sends you the bad news.
Speaking of lawyers, there’s a great new service on line called 123defender.com in Los Angeles, where you can get quick access to an affordable Los Angeles drunk driving lawyer if you’ve been arrested on DUI charges. I’m not sure if they are in cahoots with Los Angeles injury attorneys, but you can certainly ask.
There’s a similar service that is more national called lawywers.com where you can find a DUI lawyer Redwood City, for example, or a nursing home abuse lawyer in just a few clicks. I have a relative in Dallas that was injured in a car accident and she found a great car accident law firm on the site that helped her get her case through the system pretty quickly and now she’s waiting on a settlement.
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