Maureen Lamb
Maureen Lamb, founder and CEO of Medical Bill Support, LLC, a medical-billing advocacy group, Holderness, New Hampshire. She is a member of the Alliance of Professional Health Advocates. MedicalBillSupport.com
Bottom Line: Off the hook for a $20,000 charge
Few things are quite as frustrating, time-consuming or financially and emotionally fraught as dealing with large, incomprehensible medical bills. Before you give in, read on to find out how other consumers have fought back—and won. (Names and certain identifying characteristics have been changed to protect patients’ identities.)
Get your insurer to pay up when you’ve opted for an out-of-network provider. The key here is to arm yourself with information about what any out-of-network service you will be having should cost.
Example: Jim chose an out-of-network surgeon for an outpatient procedure knowing full well that his out-of-pocket costs would be higher than if he had gone with a doctor in his health insurance plan’s network. But afterward, when the surgeon’s bill arrived, he was shocked to discover that his insurance was covering only $500 of the $3,000 total.
When he called his insurance company to ask why the reimbursement was so low, a representative said that the insurer had used what’s known as the “usual, customary and reasonable” (UCR) formula to determine what other providers charge for the same service in the area where Jim lives. But Jim sent the bill to a patient advocate, and her examination of the insurance company’s explanation of benefits (EOB) revealed that the UCR was way off. Upon further investigation, the insurer realized that it had used an incorrect pricing formula. After it reprocessed the claim, Jim’s share of the bill was only $50.
Fight-back strategy: First check your insurance plan for its policy on out-of-network coverage. If you think that the reimbursement you are getting for an out-of-network provider’s bill is too low, call your insurer and ask for an explanation. You also can ask your provider to check whether the procedure was coded properly—coding mistakes can lead to underreimbursement or even a rejected claim.
To check whether you’re getting correct information from the insurance company, search the database at Healthcare Bluebook or FAIR Health to find the UCR rates for hospital procedures, lab tests and more by zip code. If you find a higher UCR than the one your insurer is applying, request that it use that higher amount, which should increase your reimbursement.
Don’t pay for someone else’s oversight. As the executor of his father’s estate, Michael tried to resolve an outstanding $10,000 hospital bill that his dad had incurred before he died. According to the paperwork, Medicare had paid its share, and his father’s secondary insurance should have covered the balance but had not.
When Michael called the secondary insurer, he was told that it was too late for the insurer to pay the bill. The hospital billing office, it turned out, had not submitted the claim to the secondary insurer within its required time frame. The hospital admitted its error and, upon request, wrote off the $10,000 balance.
Fight-back strategy: Never pay a health-care bill until a private insurer or Medicare and your secondary insurance have paid their share. Also, be aware that every insurance company has a “timely filing limit.” Generally, in-network claims must be submitted by the provider’s billing office within 90 days of the date of service, and for out-of-network claims, the submission limit generally is 180 days, but this time frame varies. Check your insurance statements to make sure that your bills have been submitted to your insurer, and if they haven’t, follow up with the provider’s billing office to request that this be done.
Tip: If you are on Medicare, set up your own account on Medicare.gov so that you can review the payments for your bills there. If you have secondary insurance, make sure that the provider’s billing office has your information and that it’s correct—if it isn’t, you will never be billed correctly.
Get help for an unavoidable out-of-network bill. When three-month-old Tyler experienced severe breathing problems, his parents rushed him to the closest emergency room. Tyler was admitted to the hospital for several days, resulting in a bill of $25,000. But because the hospital was not considered in-network, the parents’ insurance company paid the bill at the out-of-network rate, which resulted in a balance of $20,000 billed to the parents.
They asked their insurance company to pay the bill at the in-network rate because it was an emergency and they had had no choice but to use the closest hospital for their son and keep him there until he was well enough to be discharged. But neither the insurance company nor the hospital billing office would budge despite the parents’ multiple calls. Finally, the parents appealed to their state’s insurance commissioner, and then the insurance company agreed to pay the entire outstanding balance of $20,000.
Fight-back strategy: Even when you think you’ve done everything right, you may be hit with a surprise medical bill—and find no relief from your insurance carrier or service provider. If you are covered by employer-sponsored insurance, you then can contact your employer’s human resources department to ask for help—an HR staff member might be able to go to bat for you with the insurer. Or you may be able to appeal your case to the state insurance commissioner (search at NAIC.org) or attorney general. (To find your attorney general, go to NAAG.org.) Provided you have a legitimate extenuating circumstance, their intervention might induce the insurer to pay an additional amount.
Don’t let a simple mistake derail you. John and Sally’s son Peter had a chronic medical condition that they managed with medications costing $600 a month. With insurance, the parents’ share of the bill was reduced to $30 a month. But things changed when Sally and John divorced and Peter had to be transferred from his father’s insurance plan to his mother’s new plan. In the tumult around the divorce, both parents forgot to update the pharmacy about the change of insurance and the new billing address. As a result, the monthly $600 invoices accumulated at an old address, unprocessed by the new insurance plan. Eventually the bills were in danger of being sent to a collection agency.
Fight-back strategy: Always make sure that your insurer has your correct home address so that you can review your EOB statements along with your bills to make sure that they are correct. If you spot any outdated information, contact your insurer immediately. Even better, instead of relying only on snail mail, set up an online account with your insurance company—then you can proactively check to make sure that your medical bills are being received and paid properly.
