Updated: Jun 27, 2018
Getting a $1500 bill when you thought a procedure would be covered is exactly 0% fun. Here are some things I've learned that might help you avoid or navigate a similar situation.
This post's topic, so far out of my normal wheelhouse, was a request for the daughter of a family friend who is just starting to handle her own insurance. It is meant for my fellow young adults or anyone else who is newly involved with the byzantine world of medical expenses in the U.S. You might think the information below is obvious, in which case, you're probably not the target audience--no hard feelings if you click away after a cursory skim.
I am not an expert, but the following tips have saved me money and have helped me be a more informed consumer/patient. If you're involved with the industry/have more experience than me and have suggestions/corrections, please leave a comment or contact me, and I I can make updates to this page!
1. When in doubt, ask. If you don’t know if a treatment is covered or if you can go to a particular provider for the treatment, do not assume that you’re covered. Some providers might be out of network, and if you go to them, a covered service might suddenly cost full price, or even full price and then some to punish you for having the gall to leave the cabal network. Make sure you ask questions before seeking treatment.
2. To estimate your healthcare costs, you may have to contact your care provider, rather than your insurance company, or your employer. Be persistent if you don’t get solid answers. An insurance representative has told me that they cannot provide a cost estimate because they don’t know how my provider would code a doctor visit or service. If this sounds absurd to you, then we’re on the same page. I mean, how are you supposed to make sound financial decisions about what care to get when you can’t get a straight answer on how much something will cost you! If you don’t get a clear answer from your insurance company, call potential providers and ask about how they bill things, and what your estimated costs would be. I’ve found that they’re more likely to be able/willing to give a straight answer.
3. Ask you provider what your treatment would cost if you didn’t use your insurance. I have had high deductible plans. That means, essentially, that you have to pay a lot out of pocket before your insurance starts footing the bill. Toward the end of an insurance year I knew my deductible would not be met before it “refreshed” and I had to start paying into it from zero. On a whim, I asked my provider what the treatment cost would be if I didn’t run the payment through my insurance. I figured that my insurance had negotiated a lower cost, and that it was worth paying into the deductible, even if my insurance wasn’t contributing anything to the bill. I was very wrong. The provider informed me that patients paying out of pocket paid 30% less than those who were running their treatments through insurance. So I was paying for insurance, and my insurance was causing me to pay more, not less! Now, I cannot explain the kind of byzantine logic that lets them do that and still sleep at night. But I can tell you—Always ask your provider what the cost would be if you chose to pay out of pocket. You may find that it’s a better deal, especially if you have a high deductible plan, are in good health and aren’t likely to meet your deductible, and/or are toward the end of an insurance cycle and haven’t met your deductible.
4. Read your Explanation of Benefits. Seriously. An Explanation of Benefits (also known as an EOB) is issued once you have been treated and the costs of your treatment have been processed through insurance. They contain information about what you are being billed for, how that relates to your coverage, and what costs might be outstanding. Make sure you read them, because if you have outstanding bills, you want to make sure they reflect the services you received.
5. Keep good medical records. Knowing your medical history is generally helpful, and doubly so when dealing with insurance. Keeping track of diagnoses, symptoms, treatments, prevention efforts and well visits is like keeping maintenance records on your car. It helps direct future care and can help you troubleshoot problems efficiently. It can also help you if you ever need to file a dispute (see below). I have physical and digital folders for copies of medical documents and my own comments/notes. I keep copies of:
Anything I sign (Take a picture on your phone, or ask the front desk at your provider to make a copy for you.)
Old records (Request copies when you change providers or finish treatment. You may have to sign a form to allow them to send you a copy of your file.)
Names and dates of conversations you have had with customer service people or providers about coverage, treatment, or billing.
6. Whenever you talk to anyone about care, scheduling, and especially billing, ask for names, write down dates and times, and take brief notes about your conversations. The first few times I made these calls, I felt awkward asking customer service people their names. I worried that they would classify me as an “I’d like speak talk to your manager” kind of customer. You have to push through the awkward-factor—it is really important to accurately record who you talked to, when, and what they said, especially when hundreds or thousands of dollars are at stake. I try to remember that it is their job to talk to customers, that people like to be called by their names, and that if I make a point of being kind and thanking them by name, I’m helping protect myself while also honoring their humanity and their efforts to help me. Having worked in customer service myself, I know first-hand how much of a gift it is to have someone ask my name, genuinely ask how I am doing, and thank me for my help, however small my role was, and even if I’m “just doing my job.”
7. Be kind. Odds are, if you have an issue with insurance, the representative on the phone when you’re dealing with the problem did not cause the problem. When they say they’re just following policy, no matter how moronic that policy might seem, they're just doing their job. Treat people well, keep a civil tongue in your head, and don’t bother raising your voice. Instead, keep to the facts, and calmly express frustration if you need to, without blaming the customer service rep. The following script might be helpful: “I know you did not cause this issue, so I’m sorry if I sound frustrated. Here is what happened—can you please help me sort this out?”
8. If you suspect there has been an error in your billing, contact your insurance company and your treatment provider. There may have been an error in the codes entered on the provider’s side, or an error with your insurance. Or your insurance provider is just full of crap and would like some extra money (it happens). If it’s an issue with your insurance, you can file a dispute. Clearly and honestly describe the problem, and ask for help in resolving it. If the customer service representative doesn’t bring it up, you can ask directly to dispute the claim. When you make this call, have your notes ready. The representative may ask you to make a statement for them to record in the dispute file. You will want to have a concise, honest account of what happened, what you think the problem is, who you talked to about the issue, and what you would like to happen.
For example: “Hi, my name is (your name). I just read my Explanation of Benefits for (insert claim number here). I was dismayed to see that after talking to my provider, (insert name of medical provider here) on (insert date/time) and to (insert name of customer service rep) at (insert name of insurance company) on (insert date/time), I had been charged three times the estimated cost of the procedure, and was charged for a follow up treatment that I never booked. I would like the cost of (name of procedure) to be adjusted to the agreed upon amount, and the charge for the follow up to be deleted. Thank you for your time and attention to this matter. (Optional step of kindness and kudos: “Kudos to (names of helpful customer service agents, if some of them have been helpful) for guiding me through the process so far.”)
9. If they tell you your dispute is unlikely to work out, make it anyway. I once got a bill for nearly $1500 for a service I was told should be completely covered. In a worst-case situation, I might have to pay $500. Because I read the Explanation of Benefits, I knew I had been wayyyyyyyyy overcharged, and I filed a dispute. I was told that I was very unlikely to have a successful dispute and be reimbursed. The customer service rep was kind though, and she took down my statement. Though I received absolutely no notification that the error had been fixed (I assumed that she had been right, and that I would have a giant bill to deal with), I logged into my account online to find that the EOB had been updated to show about 1/3 of the original cost. There was absolutely no notice that the change had been made, there was just a new EOB. I was glad I had downloaded the old, erroneous one (it had been deleted without a trace), or else I might have thought I was hallucinating. Moral of the story—file the dispute, and keep your own copies of anything questionable or problematic!
10. Do not be intimidated if you feel clueless. I learned all of the above from actual situations that I had to figure out through trial and error. If you have insurance through your employer, it’s entirely possible that they have an expert on staff whose job it is to have some clue what is happening. Definitely use them as a resource! If you’re pretty much on your own, do not despair! Asking lots of questions, keeping good records, and being kind to everyone you talk to are your best bets. In fact, those things help with just about any learning process!
I hope these suggestions are helpful! Allow me to repeat for good measure—I AM NOT AN EXPERT. None of these things are guaranteed to work, and I can’t say they’re the perfect things to try. These are simply things that have worked for me. Hopefully I can shave off some of the learning curve for you, so you don’t have to feel as much uncertainty, or feel alone in the “what the actual heck” moments that are part and parcel of dealing with the bizarre world of medical billing.
With love (and wishing you a speedy recovery if you're ill or injured!),