Healthcare is undeniably complex, and so is its pricing. Insurance design has become so complex that even healthcare experts have become the victims of surprise billings.
There are multiple factors in play when it comes to how much a visit to your doctor office or hospital stay will cost. The two most common reasons surprise bills exist are claim denials and out-of-network providers.
First, there are multiple pricing tiers, starting with the chargemaster, the “full price” hospitals or doctors charge. Insurance companies often negotiate a percentage of charge which is called the reimbursement rate. As a member of an insurance plan, you are responsible to pay a portion of that amount (the co-pay) or the full amount (if you haven’t hit your deductible or out of pocket maximum).
I have insurance, why do I still get billed?
Even though you could purchase insurance to protect yourself against adverse health events, there are two common scenarios that explain why you get the bill: insurance companies can deny a claim submitted by the hospital or determine that the hospital is out of your network. In both cases, you are responsible to foot the entire bill.
If the claim is denied, you are usually responsible for the entire negotiated amount. If it is an out-of-network hospital, you may have to pay the full price.
What If I don’t have insurance?
Insurance companies function as your “guardian angels” when it comes to healthcare billing. But this is not always the case, sometimes, you are still being billed for services. In fact, one in 5 insured U.S. adults had received a surprise bill in the past two years.
Not having insurance doesn’t mean you are at a dead-end when it comes to receiving a medical bill more than you can afford. More often than not, there are publicly available resources and charity programs sponsored by the hospitals to help you pay the bill.
How to avoid getting surprise bills?
The best way to not have to deal with surprise billing is to be aware of preventative measures. Here are some tips you can follow to avoid getting an unpleasant bill from your doctor:
Read and understand your health insurance policy. Insurance has limitations and it does not cover everything. Read this article.
For non-life-threatening conditions, urgent care and retail clinics are much better options. The emergency room is the most expensive place you can go for basic conditions like UTI, flu, and even minor injuries.
Always ask for a receipt after each visit to make sure you have the final amount on record.
If you don’t have insurance or have a high deductible health plan, Mira could be a great option for you to get guaranteed prices for preventive, urgent care, and lab tests.
I just received a surprise medical bill, what do I do next?
1. Contact the revenue cycle (billing department) for an itemized bill
Things can happen very fast and in a blur at the hospital, as a patient, you may not be aware of everything that was done. One way to make sure is to contact the billing department and ask for a bill with “the lowest level CPT and MS-DRG codes”. CPT and DRG codes are unique identifiers assigned for each procedure and diagnosis.
2. Make sure all procedures are coded accurately
Hospitals are reimbursed differently depending on the diagnosis and procedures done. For example, an episode of sepsis (infection) could cost 5 times as much if you were put on a mechanical ventilator (W MV) compared to one without any major complication or comorbidity (MCC). You can request a review of the codes with your attending physician or get a second opinion to make sure all codes are accurate.
3. Check if there were any denials from the insurance
You can also request an “explanation of benefits” statement from the insurance and see what is the total allowed (covered) amount and the amount not covered. Determine what was not covered and cross-check with your insurance policy to see if they are correct. You can contact your insurance and ask to file an appeal form should you think there are mistakes made in the process.
4. If you don’t have insurance and are low-income, Medicaid could cover you retrospectively, but apply ASAP.
If you make less than $20,000, depending on the State, you could be eligible for government-funded Medicaid plans. In most states, Medicaid will cover you retrospectively up to 90 days for unpaid medical bills from the application date.
5. Try to negotiate.
This is perhaps the trickiest partif everything is checked out and you indeed are responsible for the amount. It is not the end of the road, you can still call the hospital’s revenue cycle or billing department (it may take several phone calls to reach them) and see if there is a discount or payment plan.
Most not-for-profit hospitals are required to provide charity care (free care) in exchange for tax-exempt status, these programs often require you to show financial proof and evidence that you’re not eligible for any government-assisted programs. Try to research and get in contact with someone who is responsible for the “charity care program”.
6. Set up a payment plan
Almost all healthcare providers allow you to set up a plan for monthly payments with or without interest. The billing department can also help you do this.