Major medical problems can turn into major financial problems for those who lack Medicare or health insurance. They can be just as costly for those who do have health coverage if Medicare or insurance won’t cover the bills.
There may be a way out. Insurance or Medicare can be convinced to pay up, or health-care providers can be convinced to pare down charges.
Before receiving any potentially expensive nonemergency medical treatment…
• Ask your insurance company to confirm that the health-care provider is in its provider network. If you have Medicare, ask the provider to confirm that it has a participation agreement with Medicare and accepts Medicare’s approved amount as payment in full. If it doesn’t, find a health-care provider that does.
• Read your insurance plan’s benefits booklet (or online benefits summary). Pay special attention to the section labeled “Exclusions” or “Not Covered.” If you have any doubt that the procedure will be covered, contact your insurance company.
• Don’t agree to the treatment without knowing how much it will cost if you do not have insurance or Medicare or if the treatment is not covered by your plan. Confirm with your doctor that the treatment is necessary.
• Keep a log of every drug, test and procedure. Do this yourself, or ask a family member to remain on hand throughout your treatment and keep the log for you. When your bill arrives, this log will help you confirm that your bill is accurate.
Health-care providers, insurance companies and Medicare sometimes bill patients improperly. What to do…
• Compare the bills you receive from providers with the “Explanation of Benefits” (EOB) statements you receive from your insurance company or “Medicare Summary Notices” (MSNs) you receive from Medicare. The amounts that these EOBs or MSNs say you were charged should match the amounts on the health-care providers’ bills. If they don’t, call the provider’s patient financial services department. It might be a simple billing error. Or it could be a case of “balance billing,” where you’re billed for the uncovered portion of the provider’s charges. (Sometimes charges are combined and it isn’t always clear what’s been paid for.)
• Request itemized bills from health-care providers. Standard medical bills don’t always fully break down charges. With an itemized bill, you can spot double billing and charges for services not rendered. Note: You must get these from the provider — Medicare and insurance companies will not provide itemized bills.
• Scan the paperwork sent to you by Medicare or your insurance company to determine why a procedure or product was not covered or was only partially covered. Often the explanation will be that a procedure wasn’t “medically necessary,” that the bill was larger than is “reasonable and customary” or that you were outside the age range for which the procedure is covered.
Your doctor might be able to convince your insurance company or Medicare that the refusal is incorrect. Ask the doctor to write a letter explaining why the procedure was medically necessary in your case or to provide a reason why the bill was larger than usual. You can continue to appeal this decision if it isn’t initially reversed.
• Ask the health-care provider to confirm that the procedure was coded properly. Insurance and Medicare claims sometimes are rejected simply because someone in the provider’s office entered the wrong billing code.
• Determine whether an out-of-network charge is justified. If you visited a health-care provider that is not part of your insurer’s network (or one that does not have a participation agreement with Medicare), you might have to pay a significant share of the bill. If you visited this health-care provider because of a medical emergency, however, the bills should be treated as if they came from an in-network or participating provider. Sending copies of emergency room reports or police accident reports to the insurance company or Medicare could convince them that this was a legitimate emergency.
Helpful: Out-of-network bills also should be covered if no in-network provider was qualified to provide the type of care required.
The amount a health-care provider charges is not chiseled in stone. To get a better price…
• Discuss money before the procedure. Your negotiating power is strongest before receiving treatment, though it still might be possible to haggle afterward.
• Ask the provider’s patient financial services department for a “charity case application” if you are financially unable to pay a large health-care bill. If your application is approved, your bill might be dramatically reduced or waived entirely.
• Helpful: If you have a stack of bills from hospitals, doctors, labs and other health-care providers, request this hardship discount from the largest company first — typically, the hospital. Once you have written evidence that the hospital has granted you a discount, the smaller medical providers might match this discount.
• Ask for a discount from the health-care provider’s patient financial services department in exchange for prompt out-of-pocket payment. Some health-care providers are willing to cut their prices by anywhere from 10% to 50%, though others never budge.
• Tip: Stress that you want to pay, but the bill is so large that you are financially unable to do so. This is likely to be more effective than creating an adversarial relationship by arguing that the bills are exorbitant and unfair.
• Hire a professional claims advocate to assist with your negotiations if the provider won’t lower your bill. The Alliance of Claims Assistance Professionals can help you find assistance in your region.
Make sure that the advocate you hire has at least 10 years of experience in claims assistance or medical billing, is familiar with the health-care providers that you are dealing with and can provide at least three former clients as references.
Expect to be charged between $30 and $120 an hour, depending on region and experience level, or around 15% to 35% of the amount that the claims assistance professional saves you.
