Remember that trip to the doctor or dentist last month? You paid your copay, assumed your health insurance would take care of the rest and left the office with a clean bill of health — or cleaner teeth. But now you’re feeling queasy because there’s a bill in your mailbox accompanied by an explanation of benefits, or EOB, from your insurance company making it clear you still owe money.
“Some people assume they have to pay the bill,” says Erin Moaratty, chief of mission delivery for the Patient Advocate Foundation, a nonprofit that helps patients negotiate the system. “A lot of the fear is of collection agencies. They’re not going to send your bill to collections right away.”
And you could even wind up overpaying. Once that happens, it can be tough and time-consuming to get a refund, Moaratty says.
So keep your checkbook in your pocket — at least for now. We have solutions for five billing problems.
Problem No. 1: You get a bill from your medical provider for a procedure or service that your health insurance has covered in the past.
Solution: Here, it pays to be a patient with patience. The medical office’s billing cycle might be ahead of your insurance company’s claims processors. “Maybe the office has submitted the claim to your insurer and the insurer hasn’t paid yet,” Moaratty says.
So, allow 30 days to make sure your health insurance company has time to process the claim. Call the provider and the insurance company to follow up if needed.
Problem No. 2: You have a big, messy pile of benefits explanations and medical bills, and it’s hard to tell what or whom you owe. That disorganization can cost you time, frustration and money.
Solution: When you get a bill from your medical provider, staple it to the EOB. “We recommend keeping a folder, a stapler and a highlighter to organize and mark your bills,” Moaratty says. After you call your medical provider and insurance company with questions, grab your stapled paperwork and write some notes on it, including the name of the person you spoke with and the upshot of the call.
Problem No. 3: Your claim, usually paid, comes back this time stamped “DENIED.”
Solution: Don’t panic. Your medical provider may have simply incorrectly coded the procedure or treatment.
Call the insurer, ask what the proper coding is and make sure the code matches the service you received, she says.
Problem No. 4: Your claim was paid but for only a fraction of the medical service you thought was all or mostly covered. You may have seen an out-of-network provider.
Solution: You may have to pay this claim. For the future, make sure you’re seeing a provider who is in your network.
“You’re going to have larger out-of-pocket costs if you don’t use your contracted providers,” Moaratty explains. For example, the procedure costs $100, your insurer is willing to pay $60, and you’re supposed to pay 20 percent. If you see an in-network medical provider, the provider usually agrees to write off the difference between the $100 cost and the $60 your insurance pays. An out-of-network provider does not have to write off that difference, so you’ll pay more.
Problem No. 5: Your request for an important or even potentially life-saving treatment is denied because your insurer wants you to try another treatment first and/or deems the proposed treatment experimental or investigative.
Solution: First, verify that the treatment code isn’t too new to be in the computer system. If the treatment still hasn’t been classified as customary, get your physician to write a letter of appeal explaining why the treatment is necessary for you, Moaratty says. Put everything in writing, and remember facts, not emotions, are essential. Make sure the letter is sent using the “return receipt” service, so you’ll get proof that the insurer received it.
Under the Affordable Care Act, which you may know as Obamacare, you have several levels of appeal. If it’s an urgent life or death situation, the insurance company has to get back to you within 72 hours. For other situations, the appeals process can take months.
“The more information you provide in the beginning, the less likely you are to get a denial,” she says. The first level of appeal is handled internally by the insurance company. The second level of appeal involves review by an independent third party in the medical field. The insurance company must abide by a ruling in your favor.
Rx for an ounce of prevention
Follow these three tips to keep your insurance payments on track:
- Timing counts. Make sure you’re seeing providers on the schedule allowed by your insurance company. If your insurance covers a dental cleaning every six months and your appointment is after five and a half months, understand that you may have to foot the bill.
- Networks matter. Make sure the provider is in your network. Out-of-network visits may not be not covered. If they are covered, they might be more expensive.
- Get organized. Keep the bills, EOBs and receipts fastened together for easy reference. On the paperwork, jot down names of the people you talk with and any resolution.
Personal loans can be used to finance medical-related debt. Check current rates and see payment examples on bankrate.