Health Advocacy: Medical Bills

Did you know that your medical bills are (somewhat) negotiable? This is not to say that you get to decide how much you want to pay. However, with a bit of preparation and knowledge, you can ensure that you are not being overcharged for your visit.

Most of us assume that when we receive a bill from our health insurance company, the bill is correct. After all, isn't that part of the point of health insurance companies, for them to figure out the billing for us? The truth is that your provider is rarely the person who codes your visit for insurance purposes. This is particularly true if your provider is located at a hospital or large clinic. When the person providing the service is not the person who bills for the service, the likelihood of mistakes increases. Couple that with the fact that practitioners charge individuals at different rates than insurance companies and things get confusing fast. Let's break down some basic terms as well as steps you can take to ensure you aren't overpaying for your care.

Terminology

Before you call your insurance company to dispute a bill for service, you need to be able to speak their language. Your insurance company representative will likely use occupation-specific-jargon that most layfolks do not understand. While this is not necessarily malicious in intent, it is exclusionary. Don't let a language barrier trip you up. Let's review a few key terms.

• Deductible: If you have one, this is the amount you must pay out-of-pocket before the insurance company will pay for any costs. This amount is predetermined by your insurance company.
• Copay: After you've met your deductible, this is the amount you will owe at a visit. This amount is predetermined by your insurance company.
• Coinsurance: After your deductible is met, you may be responsible for covering a percentage of costs for services rendered, beyond your copay. This percentage is known as your coinsurance, and is predetermined by your insurance company.
• CPT Code: This Current Procedural Terminology code is a 5-digit number indicating what type of service you received. For example, 97810 refers to 15 minutes of acupuncture without electrical stimulation. Here is a link to a search engine which will tell you what the code refers to. Before you call your insurance company, be sure you are able to refer to each CPT code both by number and by the service it refers to. This code is usually determined by someone in the Coding Department who looks at your file, not by your practitioner.
• ICD-10 Code: This is a code is diagnostic and indicates what condition you are being seen for. For example, low back pain is coded as M54.5.

Call Your Insurance Company BEFORE Your Visit

The most crucial step you can take to ensure you are billed correctly is to call your insurance company before going to any medical appointment. When you call your insurance company, ask the following questions:

• Is this service covered by my insurance?
• Do I have a deductible? Have I met my deductible? If not, how much more do I need to pay to meet my deductible?
• What is my copay for this service?
• What is the total estimated cost for this service? Be aware that they may not be able to give you a specific answer for this question. Ask anyway.

Most insurance plans include at least one free preventative office visit as well as a few preventative lab tests and/or vaccinations per year. However, there are often stipulations about this office visit. For example, if you refill a prescription or ask your doctor a specific question (e.g. "My knee hurts. Can you look at it while I'm here?"), this visit will be billed as non-preventative. Be sure to ask your insurance company about their definition of a preventative service. Document your company's definition of preventative services, including the names of all preventative labs. Do not be afraid to ask your representative to repeat themselves or spell out the name of a specific lab if you are unfamiliar with it.

Be sure to write down the name/ID#/location of the representative you spoke with, along with the date and time of your call.

Review Your Bills

Let's be honest: no one likes looking at medical bills. Paying your medical bills without scrutinizing them is the easiest way to overpay for your health care. If you do not catch the error, no one will. Your insurance company is a for-profit institution. It is not in their best interest to double check that you were correctly billed. You must be your own advocate when it comes to billing, and reading your bills is imperative.

Compare your medical bill to the notes you took during your phone call before your visit. Were you been charged the amount you expected? Great! Pay that bill, pat yourself on the back for your thorough work, and move on with your day.

If the amount you are charged differs from the amount you expected, delve in. In my experience, the amount assessed typically differs from the expected amount in cases of labwork and preventative services. Look up the CPT codes on the bill you received.

Disputing a Bill: Call Your Insurance Company Again

Okay, so you've received an unexpected bill and you don't think you owe for the charges. You've done your prep work, now it's time to call your insurance company. Be aware that the person you speak with on this call will likely not be able to resolve your issue. Your goal during this call is to get your complaint moved up to the appropriate parties who can reverse/lower billed charges.

Explain your issue to your representative, politely. For example, if you were told that your preventative services included a lipid panel, and you were charged for a lipid panel at a preventative office visit, tell your representative. Use insurance terminology. Instead of "bloodwork" or "labwork," use the specific words, "lipid panel" as well as the CPT code 80061. Tell your representative the name/ID#/location of the person you spoke with on your first call where you learned you would not be billed the amount in question.

Remember the 3 magic letters, "P-H-I." PHI stands for Protected Health Information. This information includes your medical history and payment history and is protected by US law. The agent you speak to on the phone cannot ask you about your PHI. In the example above, if your representative asks if you have high cholesterol (as this may be a possible reason for billing a lipid panel), tell the representative she/he is asking you about your PHI and that doing so is inappropriate. While this doesn't threaten the representative, they are usually more likely to take your complaint seriously if they may have infringed upon your PHI and you know it.

Expect that you will have to wait 30-60 days after this phone call to find out if your dispute has been settled. Do not pay your bill during this waiting period. Tell the representative that you will not pay this bill until the dispute is settled, and that you will not pay any late fees if you do indeed owe for the services. Ask them to write this in your dispute. Document your representative's name/ID#/office location, the date and time that you spoke, and any specific requests you gave your representative to include in your dispute.

It is your responsibility to check after 30 days to find out if the charges have been reversed/decreased. If not, call your insurance company again. If your insurance company has decided that the charges are valid and you still think you were inappropriately charged, it's time to make a decision. Know that you this dispute may continue for at least another month and decide whether the amount in question is worth your efforts. If you decide to continue, call the insurance company and ask to speak directly to a manager in the billing department. Continue to call the company regularly to see where they are in the process of assessing your case. The more times you speak with a representative, the higher the likelihood that your case will be flagged for review, resulting in a decrease or reversal of fees.

Prevent Exorbitant Payments: The Trick to Labwork

Many insurance companies charge ridiculously high prices to do labwork (i.e. run blood/urine/saliva tests). There are many companies that provide labwork for lower costs. Some of these you can do at home with a mail-away kit, others will need to be ordered by a practitioner. Prior to having your sample taken for labwork, contact Laura to discuss whether the expected lab fee is appropriate, and to find out if there is a more economical way to get your results.

Well hot dang, that was a lot of insurance talk! If you're looking for more, click here for details on how health insurance billing works.