Surprise Medical Bills. Do you know what they are? In fact, do you feel like most, if not all of your medical bills are somewhat of a surprise? Do you understand what health care services are likely to hit your personal pocketbook and how much they will be? Have you become complacent to the unpredictability and unreliability of our health care system? Or, have you become an engaged and astute participant in your health care? As an independent health/patient advocate, I encourage and assist the latter.

Example of a Surprise Medical Bill

Let’s assume you have an emergency and go to the nearest in-network hospital to be sure your insurance will cover your treatment. While there, you have an x-ray done. Unbeknownst to you, the hospital staff radiologist is on vacation and the x-ray is read by an out-of-network radiologist. Uh-oh, do you see the problem coming? The out-of-network radiologist bills your insurance and is paid the out of network rate and you are “balance billed” the difference. What if your health insurance has a contracted out of network rate of ZERO? This situation will leave you holding the bag for the entire cost of the radiologist reading the emergency x-ray that you received at an in-network hospital. This is a “surprise” medical bill.

What are our options as consumers of health care? Here are three suggestions on how to avoid “surprise” medical bills.

What Can You Do?

KNOW YOUR HEALTH PLAN BENEFITS

Reading a benefit plan summary is overwhelming. At a minimum, know these terms, numbers and where you stand with meeting them.

CoPays – this is the pre-determined amount you will owe out of pocket for specific services. Some plans have them and some do not. Some of these co-pays apply towards your deductible and out of pocket, some do not. Know your policy.

Deductible – this is the amount of money you have to spend toward your health care costs BEFORE your health insurance will cover anything. Be aware that some health plans have both an individual deductible (for each person covered) as well as a family deductible.

Co-insurance – this is the amount of money you have to spend toward your health care costs after your deductible is met, For example, a 20% co-insurance means that you will pay 20% of the charges and your insurance will pay 80%. The percentages vary from policy to policy so know what your plan states.

d. Out of Pocket – This is the amount of money you must spend out of pocket toward your medical care to obtain 100% coverage by your insurance. The deductible might be applied toward the out of pocket, but not always. If the deductible is included, then your insurance will cover your medical bills at 100% when your deductible has been met and additional co-insurance payments equal the defined out of pocket amount. Expenses will be covered for the remainder of the year, that is. Once January rolls around, the process will start all over again.

KNOW YOUR NETWORK

Knowing which hospitals are in your network is just the beginning. Each individual provider (doctor, lab, etc) is also in or out of network. These are common providers to be aware of their network status with your insurance:

a. Physicians – this includes not just your primary care physician, but also any specialists you might need. Anesthesiologists, radiologists, and pathologists are likely providers to be out of network for your insurance.

b. Labs – what lab does the hospital use to process tests? Is it in-house (part of the hospital and subject to the hospital’s network status? Or is it an independent lab? Knowing what labs are in-network with your health insurance plan will help ensure your bills are covered.

c. Hospitals and Clinics – Know which of your local providers are in-network with your insurance plan in advance of needing services. At a minimum, you will be able to seek services at an in-network facility avoiding any surprise facility charges.

ASK FOR HELP

If you find yourself unable to build confidence and understanding in your health plan benefits, don’t be afraid to ask for help. The research and time requirement can be extensive and the language hard to understand. Finally, Independent patient advocates can assist you so you can confidently participate in your healthcare services.

A surprise medical bill does not have to be scary or intimidating. If you take the suggested actions and arm yourself with knowledge about your health plan, you can confidently participate in your health care journey. If you need help understanding your health plan benefits, contact me here.