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Maintain Open Communication with Medical Bill Debt

July 14, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt

The Affordable Care Act is cracking down on some of the most aggressive ways that hospitals categorized as charitable or nonprofit facilities for tax exemption can seek to shake money out of patients. Reports of the new laws also often offer some of the most common advice to protect you and your family from unfair or excessive medical debt.

Always Talk to Your Providers

One of the biggest pieces of advice is to always ask up front about available charity and financial assistance programs. It’s a great idea to ask about health care costs, and detail payment options, before you sign up for any given course of treatment. But beyond this, dialogue with the provider is also a key to keeping medical bills from showing up on credit reports. It’s true that even with the best back channel dialogue, some hospital administrators will still send bills to collections, but having an open communication with the provider will prevent this in the majority of cases where reasonable financial offices simply ask that patients keep in touch about their debt and pay to the best of their ability.

Make Sure You Are Covered

Essentially, the Affordable Care Act can be seen as a double-edged sword – depending on what side of the table you are on. Read the rest of this entry →

How to handle a bad charge on a medical bill

July 9, 2012 in health care costs, Hospital Bills, Insurance Bills

The Today program at MSNBC recently published a report about errors in medical bills, with the comment that ‘Medical billing is rife with errors …’   The report has many comments from readers, most of whom also reinforce the frustrating state of affairs in  medical billing.

The report includes general suggestions for the patient from HealthCPA, a company that helps manage medical bills and health insurance paperwork..  We probably already know that error prevention is not easy or simple.  Furthermore error prevention may not even be possible for  the sick patient and helpers (if help is being given).  Still further, error prevention may involve unreasonable amounts of time and effort by those who do not have the energy or resources to deal with errors.

The dark ages of health care transparency

July 2, 2012 in Insurance Bills, Medical Care

Over and over again, the health insurers, my employer and leaders at the State House tell me that one key to controlling health care costs is getting patients to look for the best value in health care.

Well folks I’m trying and getting a little tired of banging my head against the wall I hit when I ask my insurer or doctor or hospital how much anything costs.

Last week I spent 30 minutes on the phone trying to figure out how much my insurer would pay a counselor for my daughter. The counselor is “out of network” (a situation more and more of us are encountering) so I have to appeal to get help paying for my daughter’s visits.

There’s a question on the appeal form that asks, “Will your provider accept the network rate?” I’m happy to ask her, but I need to know what the rate is, so I call the 1-800 number on the back of my card. Here’s a summary of the ridiculous conversation I had with the agent (who was nice and tried to be helpful)

Me: (after explaining the form) I am calling to find out the network rate for providers who counsel adolescents. How much do you pay?

Customer Service Agent (CSA): Oh I can’t give you that, there are hundreds of possible codes that could apply to your daughter’s counseling visit. Read the rest of this entry →

How to be Your Own Best Advocate

June 15, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medicare, Member Stories

Being Your Own Advocate

In case you haven’t been paying attention to changes in America’s health care system, there’s a general idea that needs to get out to as many people as possible: the gist of it is that, in most cases, today’s consumer needs to be much more engaged in their care and ready to act as their own advocate in order to get the health care and treatment that they need, no matter what their health is like.

You may have heard something like this already: from all corners of the health related media, patients are hearing that they need to “be their own advocates” and get vigilant about not just what they pay for health care, but what kinds of health care they receive and whether or not it fits their specific needs.

But what does it mean to be your own advocate? Looking beyond the cliché, you can obtain good, concrete ideas of how to go about interacting with a family doctor in ways that will help you get better access to the health care you need.

Patient Engagement: What it Involves

The good news on this front is that you may already do a lot of what you need to do to advocate for yourself in a healthcare environment. Read the rest of this entry →

Are You Being Treated by a Subcontracted Doctor?

May 28, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medicare

A recent story from Dayton, Ohio, caught our attention, where according to news reports, some patients remain responsible for emergency room charges when a hospital happens to ‘subcontract’  doctors who may not accept health insurance at all. This adds another layer to the oftentimes confusing in network vs. out of network debate. In many cases, especially in an emergency situation, patients who visit a local hospital or facility may experience unexpected costs after they are cared for by a doctor who may not be ‘in their network’, even if the facility itself is listed as an in network provider. There’s been a lot of discussion whether this, which may seem deceptive, especially to those without specialized knowledge in the medical billing and health insurance field, is fair. In fact, state officials, like in New York, are  looking to pass legislation which mandates better transparency for out of network charges. Taking the time to understand your health insurance plan and what defines a covered provider or facility can save you hundreds if not thousands of dollars in non-covered charges.

It seems providers tend to respond to these scenarios in two ways: Some indicate they will change their policies to include more transparency while others claim to be bound by federal laws that do not allow them to reveal to patients whether an on-call doctor or a physician on shift will accept their insurance or not.

We find the second argument to be completely unacceptable at face value. In fact, it’s reasonable that consumer advocates would expect state regulators to crack down on these well documented examples of seemingly unfair provisions in delivering medical services. It’s not outside the realm of possibility that a patient facing bankruptcy after a bill like this would have a basis for legal appeal, especially as new legislation is introduced and passed. It’s vitally important that you discuss your options and ask questions before treatment to minimize impact to your financial future. How prepared are you in the event of an emergency room visit?

Tools For Estimating Health Costs Getting Better — Or So They Say

May 16, 2012 in health care costs, Insurance Bills

Boy, is this a trend, from plans for Massachusetts health reform to the private sector to health insurers, but if it’s such a trend, how come we still seem to be so nowhere on it??

The excellent has a new post titled: Health plans providing detailed cost estimates of doctors visits. It begins:

Health insurers have replaced online tools that showed only rough guesses as to how much a doctor’s visit will cost with new ones that estimate specific dollar amounts for both overall and patient out-of-pocket costs.

During the past year, several health plans have released new versions or made significant updates to their cost estimation tools. The newer tools show not just a negotiated price but also the anticipated cost to a patient based on his or her benefit plan, as well as how much of the deductible is met. The projection is accompanied by a disclaimer noting that the insurer can’t guarantee its accuracy, but insurers say their updated tools are far better than the old versions.

All well and good, but all you Savvy patients out there, has anybody ever actually gotten useful cost info from your health plan in advance?

Beware of Balance Billing in Hospital Bills

May 12, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills

Balance billing occurs when a healthcare provider bills a patient for some or the entire amount that should have been declared an insurance discount (contractual allowance). The fact that Prime Healthcare Services in California recently settled a suit for $1.2 million and discontinued the practice suggests that this is a problem. In fact, several states have statutes that prohibit balance billing.

How do you tell if you’ve been balanced billed? First, you have to determine if your treatment was performed by an in or out-of-network healthcare professional. Then, you have to check your EOB (Explanation of Benefits).

In- Network

Check an erroneous charge simply by seeing if the bill for the service exceeds the amount on the EOB. If it does, let your insurance company know and let them handle it.

Out-of-Network (OON)

There are two scenarios:

  • If you have an OON benefit, the OON deductible and co-insurance will apply first. The insurance company pays the balance above that like always. However, if the provider billed you for more than the deductible and co-insurance you may be the victim of a scam. Check the EOB. Did insurance pay the provider? If so, report it. It’s a scam and it is wrong.
  • If you do not have an OON benefit and accidentally got treated by the provider, tell them you want to be treated like an uninsured patient. A standard discount will be applied.

When in doubt, check with a medical bill advocate.

Past Due Medical Bills: When Do I Have to Pay?

May 5, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt, Medicare

Have you received a medical or hospital bill with no clear due date? This can be because of how bills are laid out or because of design issues. Typically, a bill or patient statement will show medical debt as 30, 60, or 90 days past due, providing the kind of urgency that can make you drop a check in the mail. Bills may also be labeled “second notice” or “third notice” to show that the biller has already tried to contact you. But, all of that doesn’t always tell you what you need to know: how long you have to pay before the bill goes to collections. There are several reasons you may choose not to pay your medical debt right away including having a lot of bills or long-term debts to juggle. Prioritizing which ones to pay can take precedent to stay afloat. And, some billing statements require real, actionable steps while medical bills seem to be written in some strange, esoteric language.

Medical Debt Collection: Common Practices

Every medical provider has their own system for handling past due bills. Some are quicker than others to send a past due bill to collections. Many have different billing systems that represent debt in different ways. Some may be explicit about a due date, others will not. In some cases, when patients call, the medical office admits that they don’t even know the exact date when a bill will go to collections. That’s what motivates many experienced consumer advocates and others to recommend “playing it safe” and promptly paying all past due medical bills aged longer than 30 days, which is a common grace period for payments.

Some patients, though, will make active attempts to talk to providers. Those who pick up the phone can often get on payment plans that will make due dates and everything else much clearer, while allowing for deferred payment according to the patient’s finances. Some can even qualify for charity. In many cases, it’s this direct communication which can yield benefits for both parties: you know where you stand and your provider receives data on how and when you are likely to pay a particular bill. It’s a win-win, and that’s why when it comes to vague patient statements, the direct approach is often best. How do you promote open communication with your provider on past due medical bills?

Overused and Unnecessary Medical Procedures

April 28, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt, Medicare, Member Stories

Nine physician specialty societies are each reporting a top five list of commonly used procedures that are often unnecessary. These societies represent 375,000 physicians across the country.

Some of the procedures cited include:

  • Brain scan after fainting (without other relevant symptoms)
  • Antibiotics for sinusitis (while typically resolving itself in two weeks, 80% of patients are prescribed antibiotics. CT scans are also usually unnecessary.)
  • Admission and pre-operative chest X-rays (routine X-rays are not needed.)
  • Colonoscopies (not recommended but once a decade.)
  • Cardiac stress tests (they do not need to be part of a checkup for a healthy adult.)
  • Lower back pain (unless another ailment is suspected, X-rays are not needed in the first six weeks.)

Unwarranted testing can lead to stress, over treatment, higher medical bills, and even unneeded invasive procedures.

In fact, the natural tendency to screen for heart disease prior to having any symptoms, like getting a stress test as a 50th birthday present, hasn’t “panned out,” according to a preventive cardiologist at Northwestern Memorial Hospital.

Study members suggested that patients and doctors have to thoroughly discuss any tests/procedures even if they are suggested by patients because they are not always needed.

Now at COSTCO, health insurance

April 26, 2012 in health care costs, Insurance Bills, Member Stories

I buy a carload of food at COSTCO every month, so when I heard they were teaming with Aetna to sell health insurance, I had to check out the offer.  I shopped from a zip code in Texas, because COSTCO isn’t selling these plans in Massachusetts.  And they won’t be.  These plans would violate state insurance rules.  One example…Massachusetts caps individual deductibles at $2,000/year.  Should that change?

Here are my top three options (if I lived in one of the states where these COSTCO plan are available):

25 Million Americans Underinsured Including Middle and Upper Income Families

April 18, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt, Medicare

As current government initiatives wrestle with the issue of millions of uninsured Americans facing potential medical bankruptcy, new studies are revealing that it’s not just the uninsured who are at risk. The issue of underinsured American individuals and families is becoming a major part of today’s healthcare conversation and alerting many more Americans to the dangers that they face, even if they have access to affordable health insurance policies.

Current statistics show a startling trend, where being underinsured is becoming a common way to fall into extreme medical debt and eventual bankruptcy or bad credit situations. Research by the Commonwealth Fund that appeared in recent industry journals shows that America’s underinsured community has doubled in the past four years to over 25 million people. While the highest number of underinsured Americans are in the income range below the poverty level, research shows that middle and upper income families are being affected in larger numbers each year. Research also shows that some individuals with what others would consider healthy annual incomes are still very likely to become underinsured in the immediate future.

In general, being underinsured has to do with the cost of one’s medical bills against that person’s annual income. Read the rest of this entry →

Great PBS Documentary on Cheaper AND Better Healthcare

April 14, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt, Member Stories

Just watched ”U.S. Health Care: The Good News” (Episode: The Good News in American Medicine, with T.R. Reid) on PBS.   I was flipping through the channels and it caught my attention.  I watched ”Sicko” when it came out in movie theaters and before I finished my Coke I was convinced that we needed a major overhaul in medical care in the U.S.  It just doesn’t seem humane that people could die because of insurance loopholes or die because they don’t have enough money to pay for their healthcare.

Obviously nothing in life is free. Everything requires energy- which always equates to money in some way or another. Since energy (and money) are finite resources, the only solution seems to be in overhauling the entire system to make it cheaper to get and stay healthy.  And when I saw the part of the show’s title that said ”The Good News in American Medicine”, I had to watch.  Good news.  What is that?

I was very pleased to see there is good news out there. Many communities are doing a lot to overhaul the system and provide care to everyone, regardless of coverage, while bringing the costs way down. It was refreshing to see that people are trying and finding ways to succeed in this area.

I’d recommend watching this show and passing the link along to friends. The more people know about this, the more we have a chance at getting medical care costs down to manageable levels (and be a more humane society). The full video is here:

Upcoming Coding Changes Can Create Confusion

March 31, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care

As Americans continue to absorb the healthcare reform and projected modifications, the federal government is updating the way that medical services are coded and billed to consumers. The first mandate is HIPAA 5010, which is an update to the existing HIPAA format and the healthcare information processing systems. 5010 compliance is currently set for July 1, 2012. This will be followed by implementation of an updated coding system, ICD-10, which is to be effective October 1, 2013.

The existing coding system has approximately 13,600 codes while the updated system will have approximately 69,000 codes. The detailed coding system will allow for better analysis and treatment outcomes while providing payers with an initial claim submission that is much easier to understand. However, you may find interpreting your medical bill to be even more confusing as you may see more line item charges.

An example of this was recently reported in a Pennsylvania’s Fox News story. The patient was charged for an office visit and on top of this, she received a separate charge for a “consultation” when the doctor advised her to quit smoking.  Read the rest of this entry →

How much do I owe for out-of-network care?

March 30, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medicare, Member Stories

Looking at Medicare- vs. “usual and customary”-based reimbursement

By Robin Gelburd

Many Americans with private health insurance have plans that reimburse for out-of-network care. But consumers often don’t realize the wide variation in reimbursement rates among insurers and the implications for their wallets.

At FAIR Health, the independent not-for-profit corporation dedicated to bringing transparency to healthcare costs and out-of-network reimbursement, we have noticed that differences in formulas can make a big difference in reimbursements.  A number of private health plans are now basing out-of-network reimbursement rates on a percentage of Medicare fees – as opposed to the usual, customary and reasonable (UCR) standards that reflect actual provider charges. Read the rest of this entry →

Before the Affordable Health Care Act, Were You Locked Out?

March 17, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medicare

Locked out of medical care, that is. Who? Individuals with pre-existing conditions. Now, 50,000 of them have healthcare coverage via the Pre-Existing Condition Insurance Plan (PCIP) in their state. This is a temporary high-risk health insurance program that makes healthcare not only available but much more affordable.

For example, a patient named Deborah fell victim to a back injury. It left her unemployed and unable to afford health insurance premiums. However, when she discovered the Michigan PCIP plan, she was able to enroll in it, receive the back surgery she needed and get on the road to recovery.

PCIP makes a difference. It has allowed many Americans to get connected to health insurance and receive the medical care they sorely need. That’s because PCIP enrollees can receive that care immediately.

The Affordable Health Care Act has also helped students up to age 26 receive coverage and assisted seniors by allowing access to more affordable prescription drugs.

You can see how your state administers PCIP by clicking here.

Empowering healthcare consumers: FAIR Health online tools shed light on healthcare costs

March 16, 2012 in health care costs, Health Insurance, Insurance Bills, Member Stories, News

By Robin Gelburd

Recent survey reports have shown that current economic uncertainty and continued unemployment are compelling millions of Americans to delay or forgo medical and dental treatments.

Consumers concerned about healthcare expenses should be able to find out the cost of procedures or treatments in advance of seeing a doctor – regardless of whether or not they are insured. And, if consumers are insured, they should be able to determine if their doctors are in their insurance plans’ networks.

This is where the not-for-profit organization, FAIR Health, comes in. FAIR Health was created to bring transparency to healthcare costs and out-of-network reimbursement. FAIR Health created a free tool that gives consumers access to estimated costs of medical and dental treatments based on insurance status, level of insurance, and geographic area.

How does FAIR Health do this? FAIR Health maintains a database with records for more than 13 billion de-identified, private healthcare procedures from the last ten years. The database reflects the healthcare claims experience of more than 125 million people covered be private health insurance, making it the largest such data resource in the nation that is owned and overseen by an independent, third-party organization. Read the rest of this entry →

ideas about the design of health care exchanges

March 7, 2012 in health care costs, Health Insurance, Insurance Bills

There are some good ideas and resources related to designing health care insurance exchanges at

When is a Medical Bill Sent to a Collection Agency?

March 5, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt

A recent article in the Chicago Tribune’s March 4, 2012, issue “Small, Paid-off Medical Debt Can Mar Credit, Upend Financing for Unknowing Americans” highlighted how quickly a pristine credit can plummet when unexpected medical bill balances show up on credit reports including previously paid off medical debt. According to the Commonwealth Fund, 30 million Americans were contacted by collection agencies in 2010, an increase of over 25 percent from 2005. And, the Access Project, a research group funded by health care foundations and advocates of tougher laws on medical debt collectors, estimate that over 3 million Americans who have paid off their debt in full still have their balances appearing on their credit reports. Most of the collection actions are attributed to medical bills with the majority of outstanding balances under $250.00.

Medical bills are sent to collection agencies quicker than you think. In fact, it is common to receive a bill within a few days or so of your procedure or hospital stay and the clock starts ticking. So, what can you do to minimize your account from being turned over to a collection agency?

Colonoscopy bill

February 28, 2012 in Insurance Bills, Member Stories

I never received a billing statement by mail so I finally called my insurer, BCBS – MA. I was told by the customer rep that billing statements are not mailed to a member patient when a procedure is fully covered by a benefit. The statement was/is accessible on-line. I registered and so now I can see the statements on-line.  I have a lot of questions about the site, but I’ll focus on the topic.

I had two bills for the procedure:

One for the doctor:   Service: Surgery,   Billed:   $800,  Amount Allowed: $581.51,  Benefit amount: $581.51  , My Balance: $0.00

One for the clinic:    Service:Existence,  Billed:  $1750,  Amount Allowed 605.88    Benefit amount $605.88. My Balance $0.00

Existence is my term. I presume this item is strictly overhead cost. This physician formerly worked out of Emerson Hospital, but now has his own facility.

There is no itemization. Actually there is nothing to indicate that I had a colonoscopy at this visit. I went to the facility, was sedated.  Who knows what actually happened. I was not paying attention. I was picked up by a friend who drove me home.  Now I know why that friend chooses not to be sedated.

Will these records be available for the rest of my life? The web source for these pages is readable, printable. I have downloaded the pages, so I’ll see if they are parseable and thus subject to subsequent analysis.



Pull out your scalpels, we’re going to dissect some medical bills

February 21, 2012 in Hospital Bills, Insurance Bills, Member Stories

Friends and colleagues have been bringing me bills lately, asking, can you explain this? Why, they ask, is what my doctor or the hospital charges so much more than what they are paid? What happens to the difference? How do the codes fit the treatment I received?

Actually, what many people are showing me is not a bill, but an “explanation of benefits” (EOB) from their insurance company.

We’re going to take some of your bills or EOBs and dissect them to answer the general questions above and some more specific ones as well.

So send in your bills! You can scan and post them here or send me a note at We can cover an information you want to keep private.