Surprise- you got a medical bill!
I went to my doctor’s appointment and had the best visit: on-time appointment, staff was friendly, clean exam room, blood work done, prescription filled etc, paid my copay and left feeling great. Fast forward…30 days later and all of a sudden a lab bill for $75.00. How did that happen? I call the lab billing office to discuss it and they suggest I talk to my insurance company. I call the insurance company and now I am feeling like a detective on a fact finding mission and I am forced to go back to my lab’s billing office who then directs me to the doctor’s office staff to request medical records since they submitted the bill in the first place. Long story short and after a lot of paperwork in front of me, submitted billing codes were incorrect and the bill had to be corrected and resubmitted. Understandably, this is not how surprise medical bills end up for most people; in fact, most people either pay it because of a lack of patience, or never pay it at all and end up changing providers. Let’s take a moment to review what we should do to keep medical bills at bay BEFORE it becomes a surprise and not wait on the government to enact meaningful legislation. The directional path goes something like this: patient —> medical encounter—> provider staff —> bill generates —> insurance provider —> claim review —> benefit review —> contractual payment —> member cost share —> provider bill generates —> bill mailed to member —> insurance Explanation of Benefit (EOB) sent to member. #1 – Providers and Insurance companies have contractual agreements in place. Therefore, it will be hard pressed to expect both parties to display reimbursement rates on their walls in an effort to protect themselves competitively. #2- Human beings are involved every step of the process; so there is a good chance someone made an error along the way. #3 – Understand your plan benefits and associated cost share; keep your Evidence of Coverage (EOC) on your phone when you visit with your provider as you are having your conversation with him/her. Many health plans have a cost estimator tool on their apps or websites that will give you an idea of costs by service. If a diagnostic test is based on family history, make sure the doctor codes it as preventive care because if so, in most cases it will be covered as preventive care. If not, chances are you will pay in accordance with outpatient benefits (see EOC). #4- It is not the role of the practitioner to know costs. He/She is focused on your treatment plan; but support and operational staff can help you understand the costs albeit it may be an estimate. Once a treatment plan has been established, ask the provider to get you an estimate of costs based on the medical codes they plan to submit to your insurance. It is likely they will hand off those codes to a billing staff member who will translate them into a claim form with other codes that must meet the billing requirements of your health insurance plan, which may affect the estimate. Ask the provider if you can hold off on pre-payment until insurance payment determination is made. #5 – Call your insurance company and provide the given codes to them so that they too can estimate your costs and give you some advice. #6 – After the encounter and you agree to go through with the treatment and receive a bill, wait until you receive the insurance plan’s EOB and call them to help you understand the payment determination fully. #7 – Now you are at the home stretch and should by now be able to decide whether your attention should be focused on your provider, your insurance plan, or yourself! There are even protocols for patients/members to file appeals, grievances, and complaints to multiple agencies for detailed resolution, too. Good luck!