Here’s CR’s advice on how to avoid unwelcome surprises:
Understand your health insurance.
Okay, it’s not a fun read, but it pays to familiarize yourself with the rules and cost-sharing features of your health plan. How much is the deductible? What out-of-pocket costs apply toward it? Is there an extra co-pay for the emergency room?
Stay in network if you can.
Network providers have agreed to accept the negotiated health-plan price as payment in full. Even if you haven’t met your annual deductible, you’ll pay the in-network price, and if you have met it, you’ll only be on the hook for your co-pay or coinsurance.
Compare network prices.
Many health plans post some price information online. Take advantage if you can. If you can’t, call your plan’s customer-service number. If that fails, call providers directly, but be aware that some of them truly might not know your network’s price.
Don’t pay until all bills are in.
You may receive a hospital bill with scary-looking high “charges” on it. Don’t panic, and don’t write a check. They’re list prices, typically much higher than the network price you’ll actually owe. Save all provider bills and compare them with the explanation of benefit (EOB) forms that you’ll eventually get from your health plan. According to CR, you will generally owe only the “patient responsibility” amount indicated on those forms for in-network care.
Fight back against stealth out-of-network bills.
If you get blindsided by a bill from a non-network doctor after surgery or an emergency-room visit in a network hospital, you might be able to get it reduced if you make enough noise. First, ask the doctor to discount the fee. If that fails, complain to the hospital, your insurer, your employer (especially if you work for a large company) and your state insurance department or state health insurance consumer advocate.
For elective out-of-network care, find out about your plan’s reimbursement policy.
That information should be in your health-plan documents; if it’s not, call the plan and ask. Some set their own “allowed amount,” some use the Fair Health pricing database and some pay a set percentage of Medicare’s fee schedule.
Negotiate prices with the out-of-network provider in advance. Start by looking up prices in your geographical area for your test, procedure or operation at www.fairhealthconsumer.org,
www.healthcarebluebook.com or both. Fair Health also has a tool that shows what your reimbursement will be if your plan pays a percentage of Medicare’s fee schedule for out-of-network services. CR recommends using those results as a basis for negotiating a price agreement with the out-of-network provider, and getting it in writing.
For complex out-of-network procedures, prepare for lots of homework. If your procedure or surgery isn’t included on either of the sites mentioned above, ask the out-of-network provider for the CPT codes (standard medical billing codes) for each service to be performed. Also get the provider’s tax identification number and the Zip code of the location where the service will be performed. Once you have that information, negotiate with your provider as above.
Copyright 2012. Consumers Union of United States Inc.