Tag: health literacy

Surprise Medical Billing – What You Need to Know

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.

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

Is our Health Insurance Literacy improving?

Is our Health Insurance Literacy improving?

Health insurance literacy or HIL is a foreign concept to most people, but if understood and achieved at even basic levels, one can yield long-lasting effects on their health. The greater one’s understanding of health insurance the higher the likelihood for access to health care, getting medical treatment and ultimately staying healthy.  Nevertheless, health insurance literacy continues to remain at low levels in the United States.  

Defined by the Health Insurance Literacy Expert Roundtable, health insurance literacy is the degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own or family’s financial and health circumstances, and use the plan once enrolled.  The degree of HIL that one possesses falls on a spectrum from none to high.

In 2003, the U.S. Department of Education conducted a National Assessment of Adult Literacy and found that one’s overall health (from poor to excellent) is a function of the level of health literacy, and that your level of HIL correlates with which type of insurance you have: employer-sponsored, military, Medicare, Medicaid or uninsured. However, the average literacy scores of those with poor health compared to those with excellent health varied, but not significantly.  53 percent of adults had Intermediate health literacy. About 22 percent had Basic and 14 percent had Below Basic health literacy.

In 2010, shortly after the Affordable Care Act’s (ACA) went into effect, the Kaiser Family Foundation conducted a survey to shed light on Americans’ understanding of basic health insurance terms and concepts. Over half (52 percent) answered at least 7 out of 10 answers correctly, with only 4 percent answering all 10 questions correctly.  Using a grade-school scoring method, the remaining 44% would not have received a passing grade.

(Take the Kaiser Family Foundation 10-question quiz to identify your level of literacy with health insurance terms and compare yourself to others who took the quiz. You may be surprised to learn you’re as smart as a sixth grader.)

With several years of enrollment and experience in ACA health insurance exchanges, the expectation is HIL would increase.  Think again. In an analysis performed by the Institute for Healthcare Advancement in 2019, they found more than one-half (51%) of survey respondents had inadequate HIL as measured by knowledge of health insurance terms, and close to one-half (48%) had inadequate HIL as measured by confidence in health insurance use.  

If people are not grasping even the basics of health insurance or feeling confident in using it, how can we expect them to be active consumers of health care services?  Knowing how to find a doctor, fill a prescription, obtain and pay for a medication, understand the medical provider’s explanations, as well as insurance EOBs are all measures of health literacy.

HIL is not taught in school. Often, people learn about health insurance through a baptism by fire experience. If we receive a significant charge or invoice in the mail from our doctor, a common thought is “I thought my insurance covered this?”  Unwittingly, people put a lot of reliance and trust on a medical community who is driven by revenue and on an insurance system designed to minimize their risk.  Motivated financially, people become investigative sleuths navigating an itemized billing labyrinth to only discover they didn’t meet their deductible or went out-of-network not by conscious choice.

The healthcare system is flanked by healthcare providers on one side and health insurance plans on the other leaving employees figure out how it all works. If they’re lucky, their employers can step in to help.

Political efforts attempt to fix problems in our healthcare system to make it fair for people, like surprise medical billing, but legislation cannot address unintended consequences. Our healthcare system is financed by fee-for-service players driven to maximize revenue through itemized billing, and with minimal or no upfront transparency to the patient in any consolidated manner.

HIL continues to be an uphill battle for employees.  

Years ago, High Deductible Health Plans (HDHP) with Health Savings and Health Reimbursement Accounts were designed to be the great equalizer motivating people (begin treated like consumers) to take more ownership in their healthcare decisions.  Now, with over 40% of Americans enrolled in a HDHP, you would expect HIL to have increased.

A study published in Health Affairs, March 2019 illustrated how most people are not engaged in consumer behaviors.  Only one in four enrollees (24.9 percent) had even talked with a medical provider about how much a service would cost. Fewer had compared prices for a service at different facilities (14.4 percent), compared quality for a service at different medical facilities (14.0 percent), or tried to negotiate a price for a medical service (6.5 percent).  The perception of futility fuels a lack of engagement in consumer behaviors.

Employers, insurance companies, the government and even non-profits offer tools and resources for people to learn about health insurance. Ultimately, people need to take action to learn how to be active consumers and increase their health insurance literacy, and not wait for a health care system to change.