Surprise Medical Bills: Why They Occur And What To Do

Surprise Medical Bills: Why They Occur And What To Do
November 19 01:00 2016

Imagine going on Amazon, buying an Electronic Spin the Bottle Game for its listed price of $32.92, receiving the product (sparing the arduous effort required to spin the bottle) and then several weeks later receiving an additional bill for $600. As indicated in a recent study, that’s basically what’s happening in heathcare…quite frequently. Not spin-the-bottle, but the billing issue. A recent study from Zack Cooper, Ph.D., and Fiona Scott Morton, Ph.D., at Yale University and published in the New England Journal of Medicine found that 22% of emergency room (ER) visits resulted in surprise medical bills . This percentage is much higher in certain states, and surprise billing is not limited to ER visits. According to Cooper and Scott, the reason for these surprise ER bills is that when you visit an ER that is supposedly “in-network” for your insurance plan, the ER doctor that you see may not be within your network.

As you may know, many insurance plans provide more coverage for hospitals, clinics and doctors that are in the insurance plan’s network. The insurance company has negotiated particular financial arrangements with so-called “in-network” providers. Your insurance plan may cover much less or none at all for all other hospitals, clinics and doctors who are “out of network.” Therefore, when choosing where to go to get medical care, you need to check the list of “in-network providers.” Here’s a PBS segment on the problem:

But even if you do check the “in-network” list, check it twice and go to a healthcare facility that is “in-network,” there are other reasons why surprise medical bills may still appear:

Your bill may not yet reflect the insurance payments: Make sure that your insurance has already made the payment, unless you enjoy paying for what your insurance plan should cover.
Billing mistakes occurred: The administrative staff at the hospital or healthcare facility may have entered the wrong name, insurance plan, member number, billing codes, diagnoses or procedures. Double-check the bill and make sure that you aren’t being charged for a Pap smear if you are a man.

You are getting someone else’s bill: Unless you are like me, there are probably others with a similar or the same name as yours. Check your bill carefully and make sure everything matches you.
The insurance company is taking time to pay: This is analogous to being taken out to dinner for your birthday and when the bill arrives, no one reaches for it but instead looks at each other nervously. At some point, you may say, “For Pete’s sake, I’ll pay the bill for myself.” If waiting for insurance payments to occur makes you nervous, check with the hospital, doctor’s office and insurance company and document your conversations. If payment still does not occur, contact your local or state department of insurance.

Your insurance plan has changed its coverage or in-network list: The healthcare landscape can seem like a much more complex version of Tinder, with frequent shuffling, deal making, re-negotiating, merging and acquiring among insurance companies, hospitals, clinics and physician groups. Some of these changes may affect who or what is covered. So watch your “in-network” list like an athlete taking supplements should watch the banned substance list. Take heed of any notice that arrives in the mail informing you of changes in your policy.

The facility may be “in-network” but the doctor who sees you is not: Not every doctor who works in an “in-network” facility is necessarily an “in-network” doctor. For example, ER physicians may work in multiple facilities or work in some facilities temporarily. What, then, do you do if you are in the ER with a real emergency, bleeding, semi-conscious: “Before you do anything, are you in-network?” You certainly don’t want these to be your last words before you pass out.

There are other exceptions and loopholes in your coverage: For instance, your insurance may cover certain brands of medication or types of treatment (e.g., certain types of weight loss procedures) but not others. Read the fine print in your policy materials. When possible, ask whether a treatment is covered before agreeing to it. When choosing an insurance plan, make sure that you know what it covers and how.

You didn’t negotiate: President-elect Donald Trump has said on many occasions, “Everything’s negotiable.” Don’t take an unexpected medical bill lying down…unless you need to lie down.
Growing attention to surprise medical bills may motivate larger-scale changes. Some states have introduced legislative measures to curb surprise medical bills. For example, this past September, the California state legislature approved a measure that would limit what patients who use in-network facilities would pay, regardless of the whether the doctors are in-network. Also, this year a New Jersey State Assembly committee approved legislation that would require hospitals and doctors prior to treatment to reveal whether they are part of your insurance network and establish a process to settle disputes over payment for emergency care from out-of-network facilities and doctors.

Buying insurance is not like buying something off Amazon. There may be a long lag time between making the purchase and reaping the benefits. And unlike an Electronic Spin the Bottle Game (which you would presumably use all the time), you have no idea when you may need insurance coverage. Therefore, when selecting a policy, you may not pay attention to the details and use the wrong criteria to select the policy, such as choosing the policy that seems the least expensive…when you are healthy. This can be like a one-year old choosing what car to buy in the future.

Remember that the purpose of insurance is to protect you when you are not well. Familiarize yourself with what is covered should you become sick or need emergency care. Also, imagine different disastrous scenarios, what you would do, and how the insurance policy would cover each. Don’t wait until you are sick or in an emergency to get to know the doctors and healthcare system in your area. Like people, such as friends and co-workers, insurance policies can look great when everything’s going well, but you really get to know someone or something in times of need.

Read full story at Forbes
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