Medical bills can be a major factor in financial hardship in the United States. In fact, 38% of Americans say they are “very worried” about being able to afford an unexpected medical bill for themselves or their family.
38% of Americans say they are “very worried” about being able to afford an unexpected medical bill for themselves or their family.
Kaiser Family Foundation
The fear of surprise medical bills often applies to people who have insurance but simply don’t understand their health care coverage. Insurance companies don’t make it easy to know what’s covered and what’s not. And this can lead to financial challenges.
If you’re currently facing a surprise medical bill or worried about one showing up in your mailbox, here’s a few steps you can take now and later to protect yourself.
Common Causes of Surprise Medical Bills
If you’re currently dealing with a surprise medical bill, you might be asking yourself, “how did this happen”? You have insurance coverage, you pay your premium every month, and you’re almost certain your procedure is covered.
These are the most common reasons a procedure isn’t covered:
- Balance Billing
- Emergency Services
- Inpatient Care
- Diagnostics/Labs
- Billing Error
So, why are you still receiving a huge bill? One of the following reasons could have contributed to your aggravation.
Balance Billing
One of the leading causes of surprise billing is something called “balance billing.” Let’s say you go to a doctor’s appointment at your primary care physician. You go and complain of headaches, and while you didn’t expect to get anything done, the doctor sends you for some scans and bloodwork.
When you receive the care, you pay your deductible, and your insurance health plan or medicare covers the rest, right?
That’s not always the case. In some situations, you receive a bill in the mail a few months later with the remainder of the bill that your insurance didn’t cover. Why is that?
This balance bill can occur when the amount allotted to cover the procedure differs from the amount the physician or office actually charges for it.
For example, the insurance company and office might agree on paying $500 for something that costs $650. Without you knowing it, you pay your deductible or copay, and the office bills you later for the $150 the insurance didn’t cover for the procedure.
Emergency Services
More and more people are skipping medical care because they’re afraid of the cost. This issue can lead more emergency care because the problem that could have gotten solved in an office turns into an emergency room visit.
When you go to the emergency room, you never know if the doctors and health care providers there are in-network. You might think that they are simply because you’re going to the network facility. Your health policy might not cover some of the out-of-network doctors there.
According to the National Bureau of Economic Research, nearly two-thirds of ER physicians are outsourced, so they will bill you at their rates, regardless of your insurance coverage. This is another form of balance billing because they’re making up for the balance that the insurance company doesn’t pay them for the procedure.
Inpatient Care
If you or a family member were recently admitted to an inpatient care facility, that could be a reason for your surprise medical bill. The same rules apply across the board, and you likely saw one physician who is not employed by the hospital and, instead, bills at his or her own rates outside of what the insurance covers.
For example, an anesthesiologist might not be covered by your insurance, but he is the recommended doctor to work with the surgeon at the in-network hospital.
The problem is, there’s really no way of knowing this or preventing it, especially in an emergency situation. If you’re going in for elective surgery or care, the last thing you’re worried about is whether it’s covered, as well as whether the doctor is in-network.
Diagnostics/Labs
Diagnostics and labs are an interesting factor that a lot of people don’t consider. Insurance companies often don’t cover processes that they don’t deem “medically necessary.”
This issue can occur even if your doctor tells you that a lab test is medically necessary.
The insurance companies can always override coverage for something that they don’t want to pay out.
For example, you go to your primary care doctor complaining of heart palpitations. Still, you have zero history of heart issues in your family, you’re 26 years old, and you don’t smoke cigarettes.
Your doctor decides to put you on a Holter monitor that costs $6,000 to track your heartbeats and see if the monitor picks up on any palpitations.
Being that you’re young and relatively healthy, the insurance company may decide not to cover it or only cover a portion of the monitor. You pay your copay for the visit and head home only to find a bill for a few thousand dollars in your mailbox four months later.
Billing Errors
Codes apply to every medical procedure, and each code is tied to a specific insurance claim. There are thousands of codes and tons of paperwork crossing dozens of desks every day in hospitals and doctors’ offices. Something is bound to go wrong at some point.
It’s important to pay attention to the codes on your bill and do your own research. You can’t receive a surprise medical bill and assume that it’s always right, and something happened on your end.
Keep in mind that the billing and coding department may make occasional mistakes. In some cases, it could even be a miscalculation regarding codes, and they charged you for a different procedure from the one you had.
Steps You Can Take When You Receive a Surprise Medical Bill
If you’ve received a surprise medical bill, there are some key steps you should take before paying it. It’s important to understand is that you’re not always responsible for paying it. Take these steps before writing a check.
1. Review The Bill and Look For Mistakes
Billing departments make mistakes, and you might be receiving this bill for a procedure or test you never had done. The bill could be dated wrong, have the wrong code, the wrong insurance information, and so on.
Sometimes there are other reasons, such as medication brands, that your insurance doesn’t cover or even changes to the insurance policy.
Regardless of the reason, you need to have all the necessary information before calling the billing department. The bill should be itemized and easy to understand, and if it’s not, get on the phone and find out why.
2. Make Sure You Understand Your Insurance and Balance Billing
Most surprise medical bills come from people not understanding balance billing, as we talked about in the beginning. You want to make sure you know what this means and how it impacts how much you pay for procedures.
You should also know who is considered an in-network provider and look up all the doctors you saw during your stay in the hospital or wherever you were. If you find someone who isn’t in-network, that could be the reason for your bill.
Congress and the Senate passed bipartisan laws in certain states like California, Illinois, Florida, New York, and Connecticut to protect you from balance billing by guaranteeing that all doctors within the state are covered by in-state insurance.
3. Negotiate With Your Providers
If you see something on your itemized bill that your insurance company didn’t cover, find out why. Don’t let the hospital or clinic charge you for something that should be covered. It’s often possible to negotiate medical bills.
In the case of balance billing, everything is negotiable. Find out the average cost of whatever procedure you had and compare it to what the physician is charging. You can then ask them to lower the bill to that or charge the in-network rate instead.
4. Talk About a Payment Plan or Financial Aid
If you’re facing a worst-case scenario and you have to pay the bill, there are options. Only do this if you’ve questioned everything and determined that the bill is valid.
Most billing departments allow payment plans, and as long as you make small payments on time, you’ll never have to worry about the bill going to collections.
There are also charity programs and financial aid offered through many medical facilities. These programs exist to help underinsured patients pay off their medical bills and get the help they need. As long as you have proof of income and provide a bank statement, you should be eligible.
5. File an Appeal with the Insurance Company
When all else fails, file an appeal. Suppose you think that the doctor’s office or hospital isn’t charging you properly. They may also be overcharging you and refusing to negotiate. In that case, it’s time to file a complaint with the health insurance company.
In this case, you should call the doctor’s office or billing department and ask them not to send the bill to collections.
Many bills sent from doctors have a number you can call on the bill if you think you’ve received it in error. Call that number and tell them you’re appealing it, and they should agree not to send it over to collections for a certain amount of time.
How to Avoid Surprise Medical Bills in the Future
Whether you pay the bill or you prove that you’ve been wrongfully charged, you want to prevent surprise medical bills in the future. Here are some steps you can take.
Understand your Preventative Care and Medical Billing Codes
Before consenting to a procedure or test from a doctor, make sure your insurance plan covers it. Most preventative care should be covered 100%, and each service comes with its own code. Ask for the code and find out if your insurance covers it.
For example, a procedure such as a mammogram should always be covered no matter what. But, it might not be covered if you’ve already had one that year or are going to a facility not covered under your insurance.
Don’t Be Afraid to Shop Around
Even if you trust your doctor, it may be in your best interest to consider other options when facing an expensive procedure or test. While the doctor may recommend a specific facility, you may have other options.
In-network bills and care are always more affordable, and you’ll likely receive the same level of care. The out-of-network cost is likely not worth it, even if your doctor recommends and out-of-network facility.
Medical prices are different across the board, and you may be able to find a doctor who will perform the same procedure for less money if you look.
Watch Out for Facility Fees
A good example of a facility fee is when a pregnant woman visits an OB/GYN that’s based out of a hospital. That hospital might not employ the doctor; instead, he/she is using the facility to practice medicine.
As a result, the hospital will charge the patient “facility fees” because the doctor was borrowing their instruments and space for the appointment.
Have an Emergency Plan
Having an emergency plan in place can make last-minute decisions a bit easier, and you’ll be able to protect your financial future in the event of a medical emergency. Ambulance rides can cost thousands of dollar. Fortunately, you can call your local ambulance companies and find out if they’re in-network.
If you’re in a hospital and you have to travel from one facility to the other via ambulance ride, make sure the person in your care (or you) knows to ask for an in-network ambulance. It should only take a few seconds to figure out.
Final Thoughts
Surprise medical bills can be both frustrating and frightening. These bills can amount to thousands of dollars, and if you don’t pay them, they’ll ruin your credit and make life more difficult for years to come.
It’s important to remember is that the health care system will not look out for you. You need to look out for yourself when dealing with insurance companies, hospitals, and medical facilities.
Make sure you’re staying in-network, don’t be afraid to negotiate health care costs using independent dispute resolution, never pay anything you don’t understand, and always have a plan.