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How to Protect Yourself from Higher Than Expected Medical Bills

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

If you are insured and visit your local emergency room at a hospital network in your area of residence, you expect to pay the stated co-pay that shows on your insurance card, right? This is, in some senses, a reasonable expectation, but it’s not always what happens. News media outlets around the country have aggressively broadcast many cases where huge out-of-network charges for secondary providers have led to excessive medical billing amounts for patients who simply visited the wrong hospital at the wrong time.

The Problem: Hospital Network Staff Outsourcing

This major problem, that results in more out of pocket dollars than expected, really has to do with how hospitals staff. Hospitals may simply bring in outside doctors, nurses, technicians and other staff who aren’t effectively on staff at that facility, in order to help fully staff an emergency room or other hospital department. This is a convenient fix for hospitals, but what’s enraging is the idea that hospital administrators don’t think about the dramatic impact that out-of-network charges can have on patients.

What happens with out-of-network charges is that when outside physicians or other staffers happen to provide care to a particular patient, that patient is simply billed for the balance of that care because of an automatic insurer denial. Insurance companies won’t usually pay for the work of out-of-network professionals, but hospitals hire them anyway. Read the rest of this entry →

Challenging Rejected Health Insurance Claims

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

According to the AHA (American Hospital Association), 87% of hospitals expect bad medical debt to continue to grow.  And it’s no wonder with situations like a very common one experienced by patients across the nation. You are seen by your healthcare provider for a service or procedure that should be covered under your insurance plan per plan benefits. However, when the Explanation of Benefits is received from the insurance carrier, charges have been denied for coverage. What happened?

Reimbursement is based on a few key areas including plan benefits and coverage period, medical necessity, correct patient information, diagnosis code, and procedure/service code (CPT), etc. An incorrect key stroke can cause your claim to be rejected. Or, an erroneous code can result in zero dollars paid. What can you do?

Begin by appealing the rejection to your doctor and the insurance company. As described above, it may have been a simple clerical error that caused charges to be dismissed. In other situations, you want to confirm that the CPT and diagnosis codes are cross referenced. What may have happened is that the CPT code did not support the diagnosis or the reverse. Codes are chosen based on the physician’s notes, documentation, and national coding guidelines. Sometimes, the CPT code may not be specific enough or it may have incorrectly described the level of care. Most insurance companies have their own unique process and timeline for appeal submissions.

If you’ve exhausted your appeal efforts and your claim remains unpaid, you may want to file a complaint with your state’s health insurance commissioner and or enlist a medical bill advocate to navigate the process for you. Whichever route you choose, be persistent, professional, and follow through.

My Ultrasound: Three Tests, Three Pricetags

August 18, 2011 in Member Stories

My doctor said I needed a pelvic ultrasound.

Fine, I said. Do you know how much it’ll cost?

No idea, she said. But you can ask.

Great, I said. I love comparison shopping (especially when I don’t have to pay).

To be honest, I never would have shopped around for an ultrasound if not for my colleague Martha Bebinger. She’s just launched the cool, forward-thinking, social networking site, Health Care Savvy, which will serve as a forum for patients to compare prices, brainstorm on how to get costs under control and generally vent.

So, motivated to become a savvier health care consumer, I set out on my journey. Read the rest of this entry →