Surprise Medical Billing – What You Need to Know

How would you feel if you received a bill related to a recent emergency room visit, but you don’t recall who the physician was? And that the amount due on the bill was an astronomical dollar amount which your insurance plan isn’t covering? Academic researchers have found that millions of Americans receive these types of surprise bills each year, with as many as one in five emergency room visits resulting in such a charge.

The U.S. government and more than a dozen states have passed laws to help protect people against surprise medical billing. While insurance companies and physicians should work together when such bills arise, you need to know what to expect if such a thing happens.

First, let’s clarify surprise medical billing.
Surprise bills happen when an out-of-network provider is unexpectedly involved in a patient’s care. Patients go to an In-Network hospital or emergency room facility and receive services from a physician, anesthesiologist or specialist who is not in the insurance plan network. Essentially, you don’t have any control over who is involved in your case.

Physicians are not always employees of a hospital. The hospital itself may be a free-standing building considered In-Network by your insurance plan. The actual treatment you receive may be delivered and billed by individual physicians and specialists who work at the hospital, but are not actual employees of the hospital, and are potentially considered out-of-network.

Federal and state laws have been passed to ensure that insurance companies cover such surprise bills from out-of-network providers, that prior authorization is not required, that insurance companies pay those providers a fair price. In the end, you would not owe any more than you would if those providers were all in-network, which includes costs related to copayments, coinsurance and deductibles.

Visit the Health and Human Services website to read more about protections from surprise medical billing.

All of us may get surprised when we receive a bill from a health care provider. We expect our health insurance to cover things, but it can be fuzzy as to what we truly owe. You must continue to view your insurance plan’s explanation of benefits (EOB) statement once they process the claim to determine what you owe. If you believe you’ve been wrongly billed, contact your insurance plan.

When does the Surprise Medical Billing provision no longer apply?

Once you are discharged from the hospital, emergency room or ambulatory care facility, you are back to being a regular citizen responsible for choosing your own providers. Often, patients receive discharge orders that require them to schedule follow up visits with a surgeon or a specialist. While you can continue to see the same provider who treated you in the emergency room or hospital, it’s your responsibility to know if that provider is In-Network. If you continue to receive treatment from out-of-network physicians after you are discharged, the surprise medical billing provisions no longer apply.

Your employer or medical plan is required to provide a model notice or a written explanation of the requirements of surprise medical billing laws. These notices must be made public, such as on a public website of the plan or insurer. Contact your employer or insurer to read your plan’s specific notice.

Year End Health Plan Checklist to Avoid Costly Decisions

Before you head into a new calendar year, now’s the time to take inventory and prepare yourself for the unexpected with your health insurance plan. Here are a few items to consider:

Is your health plan changing?
Remember, deductibles and out-of-pocket credits don’t rollover
Did you get your preventive care check-up this year?
Spend your FSA plan balance or risk loosing it

While the majority of health plans renew as of January 1, a small number of plans renew at some point during the calendar year so these items can be applied when your plans’ renewal comes up.

Is your health plan changing as of January 1?

Whether your insurance company is changing (moving from say Aetna to Cigna) or you elected a new health plan through the same insurance company, pay attention to slight variations that may impact you personally.

Changing your health plan could mean a change in the In-Network providers. Is your doctor still in the plan? If you have out-of-network coverage with your plan, you can continue to see your doctor if they are no longer in-network, but you will now be required to pay higher out-of-pocket costs. What if you have a medical procedure scheduled for early next year or you frequent a specific laboratory for frequent blood work, will your procedures be covered as expected?

Prescription benefits can change even if your plan is remaining the same, especially the formulary drug list. A formulary drug list is a list of prescription drugs covered by a prescription drug plan. Lists are typically created as a means of negotiating better prices to due volume. You could have been taking one medication made by one manufacturer, but come to find out that it’s no longer on the formulary list. You may be forced to take a new drug made by a different manufacturer, or pay a higher price to keep the prior one.

Speciality medications are becoming more prevalent and also cost more money. As a result, special procedures and firms are now managing the fulfillment of speciality drugs. You may not be able to just visit your local pharmcy to get a drug filled. Specialty medications are often triaged to a pharmacy team at your health plan to help you manage your condition. This requires planning to ensure drug supplies are delivered timely, and if necessary that healthcare professionals are in place to administer the drug in your home. Check to see if your health plan instituted a new specialty medication process.

Deductibles and maximum out-of-pocket credits earned during the year do not rollover

You may want to get that visit in now before December 31 especially if you’ve met your deductible and you only have to pay co-insurance. Come January 1, your deductible resets to zero and you’ll have to pay out of pocket from dollar until you meet your deductible again.

Preventive Care is Covered Annually, Every 365 days

Whether its your medical, dental or vision plan, many services including preventive care are covered annually. However, this does not mean if you get your physical on November 15 you can get another physical on January 15. Most plans require you wait 365 days before your next preventive care visit is covered at 100%. Otherwise services will either be denied or covered like a sick visit (subject to deductible or not at 100%). In rare cases, your plan may cover preventive care on a true calendar year basis. Dental plans may cover check-ups in this manner.

Also, keep in mind that preventive care may be tied to your age. Most health plans must cover a set of preventive services — like shots and screening tests — at no cost to you when provided by a doctor or other provider in your plan. This includes plans available through the Health Insurance Marketplace®. You or your children may have crossed over into a new age bracket whereby preventive care tests may or may not be covered anymore. Recommend you read your health plan’s Summary Plan Description or the Summary of Benefits & Coverage to learnn more about what’s covered. You can also visit the Healthcare.gov site to learn more about preventive care.

Flexible Spending Accounts: Use it or Lose It

Healthcare FSA plans typically have a rollover feature for unused balances at the end of the calendar year. If you have more than the rollover limit, ideal for you to spend the excess funds now or make sure to submit your receipts to reimbursement before the claims deadline. The IRS rollover limit for 2021 is $550, but that does not mean all plans are required to allow the limit. In 2022, the IRS will allow plans to carryover $570 into 2023.

Summary of Action Items

Read your 2022 health plan materials and communications now to learn what changes to expect for 2022.
Visit your health plan online account to verify where you stand on your deductible and maximum out of pocket met YTD. Schedule visits before the end of the year.
Check to see if your prescription drug will be covered by the new plan.
Review your FSA account to identify balances and file claims timely. Visit the FSA Store if you need a way to spend down your FSA funds.
Contact your Human Resources/Benefits team or health plan to ask questions.

To learn more about increasing your health insurance literacy, order Maximize Your Health Insurance available on Amazon.

Save Money Researching the Cost of Healthcare

If you have the time, researching the cost of a healthcare procedure before your appointment may save you money, or at the very least ensure you aren’t surprised when you get the bill.

When dealing with a health condition, people can be consumed with their health as it may be a crisis or unexpected news. We’re more concerned with the implications of a diagnosis on our health than what it may cost us. For some, it’s the cost that will prevent them from taking the next step and getting the necessary treatment. That’s the time to pause and confirm what may be ahead of us financially. Having a clear picture of out-of-pocket costs can help to remove stress and allow you to focus on making the right decisions about our treatment.

Take radiology for example. The cost of an of x-ray can vary by provider. Health insurance plans negotiate the cost of procedures by provider in a given region further modifying the cost of a procedure. Many factors influence the negotiated price such as volume of care, clout and geographic area.

You may find if you’re willing to do a little research, you could save yourself a few bucks. You may need to travel a few miles, but the cost difference may be worth it. Often, we’re referred by our primary care doctor or specialist to a particular facility because they may be part of their network or practice. Don’t feel obligated to go where your doctor says you should go if your research uncovers a better negotiated price at another facility. Let your doctor know your situation; they should be understanding.

Use the Cost of Care Search Tool Offered by Your Insurance Plan

Most health insurance companies provide a search tool on their website allowing you to search for the cost of care for a particular procedure, and also give you a listing of providers in your zip code area who offer that procedure along with the cost. It’s essential that you ask your doctor for the full description and CPT Code of the procedure. The search tools require you be specific in your search. Otherwise, you may get incorrect results.

When you find the cost estimate from the online search tool, it typically applies the negotiated rate and any plan design features including whether you’ve met your deductible, giving you an estimated out-of-pocket cost for the procedure. If getting that test or procedure at another facility can save you money, go back to your doctor and ask them to give you the referral to that new facility. Your doctor will still get the results of the test sent back to them.

Use your EOB for Prior Costs

If you’re planning to get a test or procedure you received in the past, check out how much it cost. The EOB, or Explanation of Benefits, is the statement created when a claim is processed by your insurance plan. Log into your account on the insurance plan to search for old EOBs. If more than a year or two ago, the cost could go up due to inflation or other factors, but at least it can give you a ballpark to estimate the potential cost if performed by the same provider.

Price Transparency Tools

Over the past few years, efforts to increase price transparency to patients has yielded new sources of information the cost of care. While your insurance plan will provide the most accurate estimate on cost of care, there are other sources which can offer estimates which are not necessarily based on your specific health plan, but will offer an average cost of care.

Fair Health provides provides tools to estimate the cost of care based on claims for medical and dental services paid for by private insurance plans, including the country’s largest insurers.

Clear Health Costs is a journalism company from New York City bringing transparency to the health care marketplace by telling people what stuff costs using shoe-leather journalism, data journalism, investigative reporting and crowdsourcing.

Guroo.com was created by the Health Care Cost Institute (HCCI), an independent, nonprofit research organization. Guroo is powered by claims data contributed by some of the nation’s key health insurance providers.

GoodRx helps you search for drug prices at different pharmacies and provides coupons. Insurance is often not used in conjunction with GoodRx.

Blink Health and BlinkRx offers discounted prescription prices on medications and can analyze your insurance, copay, and deductible to find your lowest prescription price.

Review and Compare

At the end of the day, you are in the drivers seat of your health care. Being health insurance literate means understanding your choices, finding the right care and knowing what your costs will be. You may not have the luxury of time to research costs in advance. Ask the doctor’s office or treatment facility what the potential cost may be. They should be able to provide that, especially if they are In-Network with your insurance. You can always call your insurance plan and ask them for insights on costs.

Teaching Kids Health Literacy Yields Better Health Outcomes Long Term

When children learn things early in life, the knowledge sticks with them. Teaching health literacy, including basic knowledge of insurance early in life, is found to be connected with better health outcomes. When we have better health outcomes, we have healthy and productive people which can also mean lower overall healthcare costs. Unfortunately, data shows most adults are not literate about health insurance supporting the need to teach kids early about health literacy.

In their blog post, the University of Michigan Health Lab explains why making health literacy part of the K-12 education curriculum is just the prescription we need.

https://labblog.uofmhealth.org/industry-dx/a-new-prescription-for-k-12-educators-teach-kids-about-health-care

What is Health Insurance Literacy?

Are you health insurance literate? People’s literacy lies on a spectrum of knowledge with the majority skewed to the least literate side.

Do you have the knowledge, ability and confidence to find and evaluate information about health plans, select the best plan for your own (or family’s) financial and health circumstances, and use the plan once enrolled?

There is common agreement by scholars, researchers and benefit industry professionals upon this definition, but what does this truly mean for the individual who has health care needs? Following summarizes the key behaviors of a highly health insurance literate consumer:

Able to compare the key features of several health plans; understand the scope of covered services and the cost-sharing provisions associated with broad categories of services;
Assess the adequacy and fit of the provider network of his or her (or family’s) health and financial circumstances;
Assess the quality of each plan in terms of measures that are important to him or her, such as processing claims or customer services;
Understand Explanation of Benefits (EOB);
Understand his or her appeal rights; and
Know where to turn for more information and help

Additionally, knowing how to find a doctor, fill a prescription, how to use and pay for that medication, and understanding the health provider’s explanations are all essential measures of health literacy.

Translating these concepts into behaviors that yield positive results is challenging enough without the healthcare system presenting unexpected obstacles. In the end, we want our health insurance to cover the health services we receive and according to the plan design we pay for. Low levels of health insurance literacy can result in unexpected and higher out-of-pocket costs, or the delay or avoidance of healthcare altogether.

Consumers must embrace their individual responsibility to make independent informed healthcare decisions. Stepping up their game and becoming more health insurance literate will improve their financial and healthcare outcomes.

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