When you hear the phrase, “surprise medical bills,” it usually means that medical treatment you thought was in-network was actually out-of-network. As a result, your bill is significantly higher than you anticipated – thus, the ugly surprise.
Here are three common reasons you might receive surprise bills and what you can do to help prevent them.
1. Not Confirming In-Network Providers
You assumed your provider was in-network because when you asked them if they take your insurance, they said, “Yes, we do.” That only means they will process your bill through your insurance provider. It doesn’t mean they are in-network.
Or your provider might mistakenly say they are in-network or, “We think we are in-network.” Thinking they are in-network is not good enough. You want as much certainty as possible, because if what they tell you is incorrect, you will be responsible for the additional fees. Your insurer will say they didn’t give you bad information so it’s not their fault. The provider will say it’s your responsibility to confirm network participation.
How can you prevent this from happening? Call your insurance company.
Ask your insurance representative, “Is this provider in-network?” If they say, “Look on our website,” politely, but firmly, insist the representative give you that information because:
If the answer is “yes,” ask when the provider’s contract expires. You need that date because providers move out of network if they don't renew their contract before it expires. That’s particularly concerning if you are receiving on-going treatments. For example, your treatments in December may be in-network, but if your provider’s contract expires on January 1st and is not renewed, your treatments beginning in January will be out-of-network. Since billing is often at least one month after treatment, you could easily be billed for multiple treatments at higher out-of-network rates.
2. Hidden Out-of-Network Costs
If you are thinking about using an out-of-network provider, understand how much that will actually cost you. Most plan summaries clearly show that you will pay a higher deductible and co-insurance (the percentage you pay) or co-payment (the flat dollar amount you pay) for out-of-network services. But there are two additional differences that can be very costly.
3. Not Documenting Conversations
Most people either don’t document calls or take such abbreviated notes that they don’t provide the information needed to challenge a medical bill. Document all of your calls with insurance companies, providers, and anyone else associated with your bill, like a third party billing company.
Write down:
It can be hard to understand everything a representative is telling you. To be certain you’ve heard the information correctly, use what is called “active listening” techniques. By that I mean, say to the representative, “What I heard you say is…..”, then repeat what you have in your notes. Then ask, “Is that correct?” Don’t feel rushed when you’re having this conversation. Take the time you need to understand what you’re being told, and write it down. This detailed information will help you if you have to appeal the bill or insurance claim.
One final point: Language in your insurance plan document is one of the most important factors in determining how much you should pay versus the insurance company. Plan documents are not exciting to read, but it’s important you refer to them when you think your benefit is wrong. If you need help understanding your plan document or filing a formal appeal with the insurance company, consider hiring a healthcare advocate specializing in insurance billing issues.