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How do I know about how much my anticipated healthcare services are going to cost?

And how do I know I was charged a reasonable amount afterwards?

Historically (by the rules of the Old Game), the short answer was that you usually had no way of knowing how much a provider would bill your insurance company or what your share of that would be. If you tried to ask the person you were scheduling the appointment with they’d have no idea, and if forced, they’d tell you they aren’t sure exactly what services you’ll receive, regardless of why you’re coming in. In an age where your insurance company paid all or the vast majority of the bill, we lived with that. But now that you’re paying much more out of pocket, the question of ‘how much’ has taken on a whole new significance.

I wish I could tell you that things are much better under The New Game.  They aren’t.  Yet.  The Cost Beast is still applying his magic to innocent and frustrated young couples with simple and reasonable questions like ‘how much will it cost for a normal birth?’.  But there are emerging pricing tools and processes (see outpatient and inpatient checklists below) that can help you estimate a reasonable and customary rate for your market for a given procedure, test, or service.

 

The real trick in whipping The Cost Beast is making sure that:

You’re estimating for the right procedure(s).  In the Old Game, providers only billed insurance plans and not patients.  Since the two were caught in a zero sum struggle over all reimbursements, many providers developed habits of billing for the most complex procedure they could justify.  For example, there are many, many different procedure codes for a colonoscopy (colonoscopy, colonography; screening; with or without contrast; with or without biopsy).  The prices for these variations on a colonoscopy could range from ~$400 to $1800 or more in your area.  Get an estimate on the one that is closest to what can be predicted for you.  Be careful not to get an estimate on a basic procedure if you can predict that your circumstances require a more complex, and expensive procedure.

You’re estimating for all the procedures you can reasonably predict that you’ll need.  Does your procedure require supporting office visits, diagnostic tests, preparatory materials, or any other expense?  If you followed the step above, but didn’t ask this question, you may be surprised by several $100’s in other services that could have been predicted.

You’re using only in network providers.  The unintended use of an out of network provider will result in a one-two punch to your wallet;  first, you’ll be billed full Provider Charge rates, which may be several times the reasonable and customary rates.  And if that’s not painful enough, none of it will count against your in network deductible.

You’re only receiving included benefits.  If a procedure is an excluded benefit under your plan, you’ll be billed thefull Provider Charge rates, and your payment will not count against your in network deductible.

Or you’re negotiating in advance for reasonable and customary rates with out of network providers or for excluded benefits.  If you don’t negotiate rates for out of network providers or excluded benefits before you receive them (and while you have the option of finding an alternative), you’ll have a much more difficult time, and no real leverage, when trying to negotiate after the fact.

At first glance, the additional research represented by the steps below may seem like a lot of work. It is a lot of work. But it’s worth it if you can avoid unnecessary expenses and make a better-informed choice in a number of relatively common scenarios, especially if you’re on a high deductible health plan.

Signs that The Cost Beast is at work

Going to an in network provider in for an annual physical that is 100% covered by your insurance plan, thus expecting $0 out of pocket expenses, only to get a bill for labs and images ordered by your provider that your plan does not consider to be included benefits for an annual physical for someone of your age, or that are done by an out of network diagnostic service provider.

Result: $10’s to $1,000’s of unanticipated OOP expense.

Going to an in network provider in for an annual physical that is 100% covered by your insurance plan, thus expecting $0 out of pocket expenses, only to get a bill for a Problem Visit (not an annual physical) due to problem issues addressed during the visit that were unrelated to an annual exam.

Result: $100’s of unanticipated OOP expense.

Declining to go to a trusted, respected out of network physician because it’s assumed that they would result in much higher OOP expense, when that may not necessarily be the case.

Result: denying yourself access to your chosen physician, possibly unnecessarily. The OOP expense for an out of network physician may not be decisively more than in in-network physician.

Choosing to go to an out of network provider without attempting to negotiate a reasonable and customary fee for anticipated services, and instead getting billed Charge Master rates.

Result: $100’s to $1,000’s of dollars of unanticipated OOP expense.

Going to an in-network provider for an included benefit, only to find that related services are excluded benefits and getting billed Charge master rates.

Result: $100’s to $1,000’s of unanticipated OOP expense.

This is financially probably the worst one – Going to an in network hospital in for a procedure deemed an included benefit by your insurance plan, thus expecting known out of pocket expenses, only to get a bill for unanticipated consultations, diagnostic tests, or other procedures that either come from out of network providers or are excluded benefits.   Some hospitals are bold enough to consciously double-bill for facility fees and/or consumables; the insurance company may pay, for example, for the surgery and a three day recovery room fee billed. The hospital may also bill for surgical and other consumables, instrument use, or even the use of the lights. Since the insurance company assumed these facility fees and consumables were bundled into the procedure or room fees, they did not agree to pay for them separately. Therefore, by everyone’s definition (but yours), they’re an excluded benefit and you’ll get the bill.

Result: $100’s to $10,000’s of dollars of unanticipated OOP expense.

 

Let’s look at two different scenarios – an outpatient office visit and an inpatient surgical procedure – to illustrate how you can get the best possible perspective (and exert reasonable influence) on what your anticipated services are going to cost.

 

Estimating Costs and reviewing EOB’s for an outpatient office visit –

A downloadable copy of the outpatient checklist to follow: Estimating Costs and reviewing EOB’s for an outpatient office visit

Short Form

Step 1:      Choose your Provider.

Step 2:     Call the clinic to schedule your appointment, but also … Confirm that your Provider is still In Network.  Ask if they bill Facility Fees or consumables separate from procedures (a common practice for hospital owned outpatient clinics); if they do, ask how much. If the facility fee seems excessive you might check other physician practices elsewhere where there are no facility fees.

Provide your reason for visit, schedule your appointment and provide all of your insurance plan information.

Step 3:     In the same call, ask if all anticipated services (based on your Reason for Visit) are allowed benefits under your plan, and what your insurance company’s Allowed Charges are. Make sure they include diagnostic tests.

Step 4:     Ask if past patients with similar Reasons for Visit had any common unpredicted procedures.

Step 5 (optional depending on your confidence in the info gathered in steps 3 and 4): Call your insurance plan, tell them you’re seeing an in network provider, and ask what their Allowed Amounts are for the CPT codes you anticipate.

Step 6:      Go in for your appointment. Get treated. Thank your doctors, nurses, and staff who worked with you.

Step 7:      On checkout, you may be asked for some money.  Pay up.

Step 8:     Go home and enjoy life.

Step 9:     When your EOB comes later (10 – 60+ days) from your insurance company, review it carefully. Specifically look for dates of service, service descriptions, duplicates, and surprise facility fees or excluded benefits. If you made a payment when you received the services, does that payment reconcile with the amount you’re responsible for on the EOB?

Step 10:   If you didn’t make a payment up front, or only made a partial payment, then you will soon be getting a bill from your provider. It should reflect the exact amount your EOB states is your responsibility (or the difference if you made a partial payment up front).

Step 11:   Share your experience.  By sharing your experiences, insights or stories, we improve other’s chances and of making well informed choices.

Step 12:   Go back to enjoying life.

 

Detailed Form

Step 1:      Choose your Provider.

Check your insurance plan’s web site to see if your #1 choice for a provider is In Network for your plan. If so, go to Step 2. If not, consider taking some preparatory steps before you decide how important it is to you to use an in-network provider, then proceed to Step 2.

 

Step 2:     Call clinic to schedule your appointment, but also …

Confirm that your Provider is still In Network.  They should be, but on the off chance that they’ve dropped out mid-year (many insurance plans are slow to update their web sites with this info), you don’t want to pay the price later.

Ask if they bill Facility Fees or consumables separate from procedures (a common practice for hospital owned outpatient clinics); if they do, ask how much.  If it seems excessive you might check other physician practices elsewhere where there are no facility fees.

Presuming their in network status is confirmed and your OK with the facility fee answers, schedule your appointment and provide all of your insurance plan information.

It’s very important that you provide as much detail possible in your Reason for Visit, since some practices schedule different time blocks for different types of visits or request that you do different preparation.   For example, if you need your blood pressure prescription renewed and you have some questions about a pain in your foot, but you’re also overdue for a physical, tell the appointment scheduler everything.  If you were to tell them you’re coming in for a physical and thinking to yourself that you’ll just ask the doc a few extra questions about your foot while you’re there, they may not schedule the right amount of time, AND any questions in the steps below will get you inaccurate answers.

The practice may be organized to have you speak to a front desk person for scheduling your appointment, but may need to transfer you to a billing person to confirm in network status.  If so, confirm that last since you’ll want the billing person for the next couple of steps.

 

Step 3:     In the same call, ask if all anticipated services (based on your Reason for Visit) are allowed benefits under your plan, and what your insurance company’s Allowed Charges are.  Make sure they include diagnostic tests.

A billing person should know this, but if they don’t, then get the associated CPT codes and units and go to Step 5.  If they are included benefits for your plan, are they done under the provider’s tax ID?  If not, are the diagnostic service providers also in your plan’s network?  Note that this is a very carefully worded question and very few patients know how to ask it properly.  Many providers work in Medical Office Buildings that include laboratory and imaging centers owned by independent companies or the local hospital, which may or may not be in your plan’s network.  If you ask whether diagnostic tests are done ‘in your office’ or ‘in house’, or something similar, you may get a response like ‘Of course. They’re right here on the same floor, and you can get them before you leave.’  That answer assumes you’re concerned about location convenience (as are the vast majority of the patients scheduling appointments), when what you’re really asking is whether you’ll benefit from your plan’s negotiated Allowed Amounts, or get stuck with inflated Provider Charges.

Note that you need the amounts they anticipate your insurance plan will pay (‘Allowed Amount’); NOT what the provider will bill (‘Provider or Charge Master Charges’), since the Provider Charges are meaningless to you.  This will almost certainly require a billing person. If you’re talking to a front desk person, they might be coached to respond with ‘we won’t know until we see you and have billed your insurance’.  You may also get other efforts to deflect this question, since it may take some effort to look up.  On occasion, some practices have even replied with ‘We can’t discuss that because it would be a HIPAA (patient privacy) violation’, which is utter nonsense, since they’re discussing it with you!  Explain politely to them that you’d like to know before you attend, since you’ll be paying some or all of the costs out of pocket.  Be persistent, and ask to speak to a billing or office manager if you get resistance.

But here I have to deliver some disappointing news; many insurance plans have, in their contracts with the providers, deemed their Allowed Amounts to be ‘confidential’.  If the practice evokes this, you’re out of luck. Just ask what CPT codes they plan on billing and how many units of each.

Step 4:     Ask if past patients with similar Reasons for Visit had any common unpredicted procedures.

For example, if 20% of them get a certain reflexive diagnostic test based on their interview, history and physical exam, you want to know about this. Then follow with the same q’s from Step 4, and revert to Step 3.1 if necessary. Are these included benefits? Are they done under the providers tax ID? If not, is the diagnostic service provider in my plan’s network?

 

Step 5:  (optional depending on your confidence in the info gathered in steps 3 and 4): Call your insurance plan, tell them you’re seeing an in network provider, and ask what their Allowed Amounts are for the CPT codes you anticipate.

 

Step 6:  Go in for your appointment.

Get treated. Thank your doctors, nurses, and staff who worked with you.

In a survey by the Pioneer Institute after price transparency laws were passed in Massachusetts, prices for an MRI varied from $500 to $8,000.

Step 7:      On checkout, you may be asked for some money.  Pay up.

Less sophisticated practices will submit their bill to your insurance plan, let them adjudicate it, wait for their EOB, then bill you for your portion later. The more sophisticated practices will want to collect all or as much of your portion of the bill as possible, since collecting from patients directly is often difficult (and results in high levels of bad debt write-offs) after they’ve left the office. Your practice has access to the terms of your insurance plan (co-pays, co-insurance, and how much of your annual deducible has already been met). If they’ve gone to the effort of getting this from your insurance company, and if you have a high deductible plan, the bill may be hundreds of dollars or more. If they ask for this, be certain that they’re collecting from you based on the Allowed Amounts they anticipate from the insurance plan – NOT their Provider Charges.

For example, let’s assume that you have more than $1000 yet to meet on your annual deductible, and that the clinic’s Provider Charges for a Problem Visit with several labs and one diagnostic image may total $952. Assuming they’re all included benefits, your insurance plan’s Allowed Amount may be $231.52. If the practice wants you to pay before you leave, be sure you’re paying $231.52 instead of paying the $952. If you don’t, over $720 of your money will be sitting in the provider’s bank account until they’ve received their EOB from your plan and cut you a check back for the difference. The EOB that would result from this example is included below from BCBS.

 

Step 8:     Go home and enjoy life.

 

Step 9:     When your EOB comes later (10 – 60+ days) from your insurance company, review it carefully.

Specifically look for the following;

Are the dates of service correct?

Do you understand the service descriptions, and did you actually receive all the services represented?

Are there any apparent duplicates or other billing errors (which neither you nor the insurance company should pay for)?

Are there any surprises regarding included vs excluded benefits? Any unanticipated Facility Fees?

If you made a payment when you received the services, does that payment reconcile with the amount you’re responsible for on the EOB?

If you find any problems, your next best step is usually to call your insurance company, since the EOB you received is generated by the insurance company, and only they can compare it to the actual bill they’ve received from your provider. If you can’t work out the problem with the insurance company representative, then ask if the two of you can call the practice together and resolve the issue.

 

Step 10:   If you didn’t make a payment up front, or only made a partial payment, then you will soon be getting a bill from your provider.

It should reflect the exact amount your EOB states is your responsibility (or the difference if you made a partial payment up front). If you can’t pay the outstanding balance in one payment, contact your provider’s billing office and work out a payment plan.

 

Step 11:   Share your experience.  By sharing your experiences, insights or stories, we improve other’s chances and of making well informed choices.   Start by sharing your experience with the ChooseWell community.

There are also several other groups who are already sharing experiences that we wanted to make sure you know about:

If you have a condition, symptoms, or are receiving a treatment, take a look at Patients Like Me.  They provide connections with others like you for education and social support.

Smart Patients is an online community where patients and caregivers can learn from others like them.  This includes information on research, clinical trials, and personal stories.

If you’re interested in consumer feedback specific to medications, Iodine is a ‘Community of over 100,000 people sharing their medication experience and advice.’

Yelp. That’s right, the same app you used to find a good Greek restaurant when you were visiting a new town. It’s not a typo. You can either enter ‘Doctors’ in the main search window, or navigate to ‘More Categories’, then ‘All Categories’, then ‘Health & Medical’, then ‘Doctors’ followed by their specialty (or another category if something other than a doctor).

CAHPS surveys ask patients to report on their experiences with a range of health care services delivered in ambulatory, hospital, dialysis, nursing home and other settings.

 

Step 12:   Go back to enjoying life.

 

Estimating Costs and reviewing EOB’s for a hospital inpatient stay or procedure, or for an outpatient surgical center

Many of the same concepts apply just as we reviewed in our outpatient example above, except the costs associated here are likely to be much higher. And there is a new concept at this level called ‘Informed Consent’ that could have a significant impact on both your care and your OOP expenses.

A downloadable copy of the outpatient checklist to follow: Estimating Costs and reviewing EOB’s for a hospital inpatient stay.

Short Form

Step 1:  Choose your Providers carefully (lead doctor/surgeon, hospital, outpatient surgery center, specific surgeon, etc).

Step 2:  Contact your Insurance Company to confirm that my planned Providers in network. Explain the procedure(s) your anticipating, and confirm that they are included benefits. Do they require pre-authorization? If so, make sure you understand the process. Ask what the insurer’s experience has been with your selected providers in terms of unanticipated use of facility fees, excluded benefits, and/or out of network providers.

Step 3:  Prior to your pre-procedure consult, ask the hospital or surgical center for all applicable Informed Consent forms and anything else you’ll be expected to sign.

Step 4:  During your pre-procedure consult, address any questions you have (in general or from the informed consent documents).

Step 5:     Call hospital the to schedule your appointment, let them know your Reason for Visit, and also confirm that Provider is still In Network.

Step 6:  In the same call, ask if all anticipated services, including diagnostic tests (based on your Reason for Visit) are included benefits under your plan, are administered by the hospital or another provider within your network, and what your insurance company’s Allowed Charges are.

Step 7:  Ask the hospital if past patients with similar Reasons for Visit had any common unpredicted procedures.

Step 8:      Ask who you should provide copies of your Living Will/Advanced Directive, limited healthcare Power of Attorney, and (if you have one) your POLST to.

Step 9:    Ask for all applicable Informed Consent or any other forms (privacy statements, etc) from all parties.

Step 10:   Call your insurance plan.

Step 11:    Check in, and prepare to pay up.

Step 12:    Hop in the wheel chair and roll up to pre-op.

Step 13:   Go home and enjoy life.

Step 14:   When your EOB comes later (10 – 60+ days) from your insurance company, review it carefully for errors or surprises.

Step 15:   Do you need a professional Advocate?

Step 16:   If you didn’t make a payment up front, or only made a partial payment, then you will soon be getting a bill from the hospital or surgical center.

Step 17:   Share your experience.

Step 18:   Go back to enjoying life.

 

Detailed Form

Step 1:      Choose your Providers carefully (lead doctor/surgeon, hospital, outpatient surgery center, specific surgeon, etc).

 

Step 2:      Contact your Insurance Company to confirm that your lead providers are in network.

Explain the procedure(s) your anticipating, and confirm that they are included benefits. Do they require pre-authorization? If so, make sure you understand the process. Ask what the insurer’s experience has been with your selected providers in terms of unanticipated use of facility fees, excluded benefits, and/or out of network providers. They may not provide this information; if they use patient confidentiality/HIPAA as a reason (which is bogus), clarify that you’re NOT asking for any personally identifiable data. You don’t want to know anything about their identity or who they are – just what they were billed for their similar procedures. Did they get a lot of unexpected line item charges from the hospital? If they decline to answer stating that it’s in violation with the confidentiality clause in their contract with the hospital/provider, you’re out of luck.

 

Step 3:      Prior to your pre-procedure consult, ask the hospital or surgical center for all applicable Informed Consent forms and anything else you’ll be expected to sign.

Be sure to specifically ask for forms from any provider that may be a contractor as opposed to an employee (such as an anesthesiologist).  If at all possible, review all of them prior to your face to face meeting with your lead doctor.

 

Step 4:      During your pre-procedure consult, address any questions you have from the informed consent documents.

Make your lead doctor aware of who your Proxy will be during your procedure (and provide them with the appropriate limited healthcare Power of Attorney), and discuss with them the conditions under which you might either require an additional consult or an unplanned additional procedure, and when those options can be discussed with your Proxy for their input or decision prior to action. Give them copies of your Living Will/Advance Directive/POLST, and discuss to the point where you’re sure they understand your intent.

Make sure your lead doctor knows that even though you may be signing their Informed Consent document, that you’re cost conscious, since you’ll be paying a substantial amount of your bill out of pocket. Ask if she can help you be a good consumer, and be particularly conscious of;

Will your procedure likely require blood product transfusions? If so, can you have your own blood drawn in advance and given back to you (or donated if unused)? This is both safer, and can save considerable expense.

Diagnostic tests on admission; can the be done in advance at an outpatient service center? This may also help you delay your admission and spend less time in the hospital, as some procedures schedule you for early check in just for early diagnostic tests.

Diagnostic tests after admission; avoid redundancy and order only what’s necessary. If the hospital has patterns of ‘standing orders’ or ‘morning orders’ of standard battery’s of lab tests, for example, can she forgo those and only order what’s necessary? Your insurance plan may not cover such tests, unless they’re specifically ordered by your doctor for your condition/procedure. Can she be conscious of not re-ordering tests if previous tests can be used?

Use of unanticipated excluded benefits; can she work with your Proxy to first consider procedures that are included benefits, and discuss the need for excluded benefits prior to use.

Use of unanticipated out of network providers; can she work with your Proxy to first consider in network providers.

Recovery; How much of your recuperation or post procedure monitoring can be done at home?

 

Step 5:     Call hospital the to schedule your appointment, let them know your Reason for Visit, and also confirm that Provider is still In Network.

Presuming their in network status is confirmed, schedule your appointment and provide all of your insurance plan information.

 

Step 6:     In the same call, ask if all anticipated services, including diagnostic tests (based on your Reason for Visit) are included benefits under your plan, are administered by the hospital or another provider within your network, and what your insurance company’s Allowed Charges are.

Ask if they charge facility or consumables fees beyond the allowed benefits already cleared by your insurance company. Note that you need the amounts they anticipate your insurance plan will pay (‘Allowed Amount’); NOT what the provider will bill (‘Provider Charges’), since the Provider Charges are meaningless to you. This will almost certainly require a billing person or a specialized admissions person. Since there is generally much more money involved than with outpatient procedures, it’s far more common for hospitals and surgical centers to make the effort to anticipate total charges.

 

Step 7:     Ask if past patients with similar Reasons for Visit had any common unpredicted procedures.

For example, if 20% of them get a certain reflexive diagnostic test based on their interview, history and physical exam, you want to know about this. Are these included benefits? Are they done under the providers tax ID? If not, is the diagnostic service provider in my plan’s network?

 

Step 8:      Ask who you should provide your Living Will/Advanced Directive, limited healthcare Power of Attorney, and (if you have one) your POLST to.

 

Step 9:      Ask for all applicable Informed Consent or any other forms (privacy statements, etc) from all parties.

Use open ended questions like ‘if you or anyone else expects me to sign something, I’m asking for it in advance’ and ‘who will be involved in my care that is not an employee of the hospital?’. Be aware that their first response might be to say something like ‘we’ll give you those when you’re admitted’. Persist, and ask for them in advance. Some of your doctors, such as surgeons or anesthesiologists, may not be employees of the hospital, and so the admissions people might not have consent or other forms from them – but they should be able to tell you where to go to get them. It’s important that you have these forms in advance so you have an opportunity to read and really understand what you’re signing. Once you’re admitted and well down the path to your procedure, you’re virtually powerless if you question any of the terms.

 

Step 10:   Call your insurance plan.

Tell them which provider you’re seeing and what procedure you’re anticipating; confirm that;

The procedure is an included benefit; and

Ask if they have a history with unpredicted excluded benefits or out of network providers from past patients going through the same procedure.

Be aware that you might be the first patient who has ever asked this question, but don’t back down. It’s worth being very friendly and cultivating a relationship with someone at your insurance company – send cookies if you have to – who can check into this, because the hospital is far less likely to tell you, and the insurance company is really the only one who could see a pattern of this type of behavior.

 

Step 11:    Check in, and prepare to pay up.

You will almost certainly be asked for some money. The most sophisticated hospitals will have applied your insurance information, address, SSN, and DOB prior to your check in and compared that to your anticipated bill to do a complete ‘ability to pay’ analysis on you. This includes a credit check, collecting info on your annual income, and other intimate financial details. Based on this, they have already have a pretty well informed idea of what you are capable of paying, and they’ll ask for as much of it in advance as they feel they can get away with.  If you feel you’re in this situation, be certain that they’re collecting from you based on the Allowed Amounts they anticipate from the insurance plan – NOT their Provider Charges.  If your ability to pay is more limited, they probably won’t lower the total amount – at least initially – but they will put together a payment plan and ask you to agree to it in writing prior to check in.

Less sophisticated hospitals will submit their bill to your insurance plan, let them adjudicate it, wait for their EOB, then bill you for your portion later.

 

Step 12:    Hop in the wheel chair and roll up to pre-op.

Get prepped. High five your surgeon. Snarf the happy gas. Faaaddddeee aaaawwwwaaaayyy.

 

Step 13:   Go home and enjoy life.

 

Step 14:   When your EOB comes later (10 – 60+ days) from your insurance company, review it carefully, and specifically look for the following;

Are the dates of service correct?

Do you understand the service descriptions, and did you actually receive all the services represented? Does anything look silly? Did you get an unexpected or unreasonable Facility Fee? Is there a line item for ‘Mucus Capture Devices’, quantity 2, for $179.45 each? That’s a box of Kleenex. ‘Oral Admin Fee’ for $6.25 per instance, for a total of $87.50 over the stay? This was for the nurse to hand you a pill that you took by mouth. How about ‘Headlight’ for $93.50? This was for the cost of using the overhead light in the operating room. Or ‘Cup, Medicine’, 44 units at $10 each for a total of $440. This was for the little plastic cup – not the medicine inside, the cup – that the nurse used to hand you the meds you took orally.   If you find any of these, get indignant.

Are there any apparent duplicates or other billing errors (which neither you nor the insurance company should pay for)?

Is there any evidence of un-bundling? Insurance companies generally pay for a procedure or a day’s stay in a normal, ICU, or ER hospital bed, but that should include most normal disposables and consumables needed. Was there a charge for a surgical tray, then another charge for the individual components? If you start seeing itemized consumables that you suspect represent double billing, highlight them.

Are there any surprises regarding included vs excluded benefits?

If you made a payment when you received the services, does that payment reconcile with the amount you’re responsible for on the EOB?

If you find any problems, your next best step is usually to call your insurance company, since the EOB you received is generated by the insurance company, and only they can compare it to the actual bill they’ve received from your provider. If you can’t work out the problem with the insurance company representative, then ask if the two of you can call the hospital or surgical center together and resolve the issue.

The hospital will likely want to start this conversation by trying to negotiate a discount off the whole bill if you pay cash.  DO NOT go down that road.  At least not at first.  Get them to completely remove anything found under bullets 2-4 above.  Did you receive excluded benefits that you didn’t agree to in advance?  Request to get them removed completely, but bear in mind that if you signed an Informed Consent, they’ll likely refer to that as your pre-approval for anything they decided to do.  Still, give it a shot.

 

Step 15:   Do you need a professional Advocate?

If you detected problems and the insurance company couldn’t help you resolve them with the hospital or surgical center, or you couldn’t get satisfactory resolution dealing directly with the hospital, you might be in over your head – especially if we’re talking about thousands of dollars. Professional Advocates are generally experienced medical billers who have worked for hospitals, doctor’s offices, insurance companies, or all of the above, and understand the intricacies of medical billing. They often know, by Reason for Visit or hospital procedure, what some of the signs are of being overbilled.  And they are more likely than you are to know exactly what to ask or how to negotiate with the hospital to whittle your bill down as far as possible.

 

Step 16:   If you didn’t make a payment up front, or only made a partial payment, then you will soon be getting a bill from the hospital or surgical center.

It should reflect the exact amount your EOB states is your responsibility (or the difference if you made a partial payment up front). If you can’t pay the outstanding balance in one payment, contact your hospital or surgical center’s billing office and work out a payment plan.

 

Step 17:   Share your experience.  By sharing your experiences, insights or stories, we improve other’s chances and of making well informed choices.   Start by sharing your experience with the ChooseWell community.

There are also several other groups who are already sharing experiences that we wanted to make sure you know about:

If you have a condition, symptoms, or are receiving a treatment, take a look at Patients Like Me.  They provide connections with others like you for education and social support.

Smart Patients is an online community where patients and caregivers can learn from others like them.  This includes information on research, clinical trials, and personal stories.

If you’re interested in consumer feedback specific to medications, Iodine is a ‘Community of over 100,000 people sharing their medication experience and advice.’

Yelp. That’s right, the same app you used to find a good Greek restaurant when you were visiting a new town. It’s not a typo. You can either enter ‘Doctors’ in the main search window, or navigate to ‘More Categories’, then ‘All Categories’, then ‘Health & Medical’, then ‘Doctors’ followed by their specialty (or another category if something other than a doctor).

CAHPS surveys ask patients to report on their experiences with a range of health care services delivered in ambulatory, hospital, dialysis, nursing home and other settings.

 

Step 18:   Go back to enjoying life.

 

 

Next:  If you’re curious, we can take a stab at explaining how the medical billing process actually works.

 

Remember:  We coach, support, educate, and empower.  We illuminate options you may not have known you had.  But we don't decide what's right for you in your unique circumstances; only you can do that.  And we don't provide medical, financial, or legal advice; nor do we replace the valuable counsel of those who do.