Thursday, December 31, 2009
Friday, December 11, 2009
Thursday, July 16, 2009
- How do copays work? Do they apply to deductible? Most don't. That is simply what you pay out of pocket. Your deductible is the "co-insurance" part of the deal
- What is the definition of in-network and out-of-network benefits? It is important to understand what they mean by whatever breakdown figure they use (for this example I am going to use a 70/30 split).
What you will ultimately pay is not necesssarily based on what the doctor bills you. It is dependent on what the insurance company deems as "allowable". (And, all use different fee schedules there are no federal or state guidelines, although all insurance companies go off certain standard metrics).
So, let's say you get a bill for $150 for an out-of-network doctor. Your insurance company may say that $100 is allowable by their schedule. They base their reimbursement on the allowable fee of $100. So, that means they pay $70 and you pay $30. The other shoe that will drop for you is the $50 that insurance did not allow. The docts office will "balance bill" you that amount + your coinsurance. So, your total out-of-pocket costs will be $80. (Sometimes, you can get a doctor to write off that $50, but you have to be proactive and ask.). This is not the same as a co-pay.
- If you are not sure how your new insurance will treat a provider (this is usually only significant in the out-of-network scenario(s)) You can always ask for the diagnosis code(s) (ICD9) and procedure code(s) (CPT) the docts office will use for your treatment/visit.
Then go back to the insurance company and ask to run a test claim. That should give you a good guideline on how insurance will pay. When you do this, make sure to ask if the call has been recorded, and always take good notes that summarize the discussion and outcomes (include name of person, date, and summary). Insurance companies always say that no claim quote is valid until it is completely processed. Good data is key. In the event that something goes wrong, you can point to the conversation you had. It is always more difficult to recreate your memory.
- If you go to a hospital in your area, make sure you find out if both the facility fees and doctors fees are covered. Ask this of the billing department. The receptionist checking you in is often not a reliable source of information. I have come across cases where the facility is covered but not the doctor (i.e. radiologist, pathologist, emergency). It is a serious drag to not know this in advance. You think you are all covered, but then you get a $450 or more doctor's bill.
The hospital is generally not proactive in telling you this (unless you get someone who is on the ball, which in my experience is not very often.) Tell me, how many times have you asked the same question from multiple representatives of a facility or insurance company and gotten as many answers? Please note: Most say, that they do a courtesy billing. That does not mean that they are preferred providers of your insurance company.
These are some simple techniques to help you better manage your costs. Until our medical system changes and patients have better consumer control over their costs, these simple techniques have been the only way I have some measure of understanding and controlling costs.
I highly recommend doing these basic steps before you need to use services. An emergency can happen at any time, as I have found out the hard way. Once you get a handle on what the expenses are (especially your out-of-pocket ones) before you have any treatments, procedures, etc... you will be much better in control of your outcomes.
Wednesday, June 10, 2009
Saturday, May 30, 2009
- Don't blindly trust the system including the people in the system. It could have dire consequences.
- Be educated about your insurance policy.
- Make sure you know what is happening around you.
- Be your own advocate or have someone else be your advocate.
- Have notes written summarizing highlights of important conversations including names and dates.
- Bring personal small comfort objects, whatever that is for you.
- Bring earplugs and try to get the bed farthest from the door (very helpful for sleep).
- Bring a good dose of humor.
Tuesday, May 26, 2009
Wednesday, March 25, 2009
Monday, March 2, 2009
- Stay on top of complex billing situations.
- Write down notes from any conversation you have with anyone about a bill or any complex situation.
- Trust your instincts. If something doesn't seem right, it probably isn't.
- Be creative about how you approach a problem. Or, sometimes doing the same thing over and over, you will get a different response.
- Leverage your payment history (if it is good) or customer history.
- Leverage insurance payment patterns if something seems different.
Thursday, February 26, 2009
Thursday, February 19, 2009
The first outlines some of the important techniques that can be successfully employed to help reduce out of pocket costs. It comes from a real life experience of a couple that tackled their spiraling costs. I have used a number of the techniques and it mostly works. Sometimes, like I said yesterday, it is random based on who is on the other end of the line. So, it always good to try and try again. 10 Ways to Cut your Medical Bills
Another article a couple of days ago addressed how a family member stepped up to help advocate for her brother. Negotiate Your Medical Bills And, through Htzpah, persistence, looking over an itemized bill for a hospital visit (that is enough to make anyone sick) -- Crimminy, up to $10 for a Tylenol pill. It is a sad state in this country that we have come to this.
In addition to some of the techniques identified I use the following:
- Always, Always, keep notes for each conversation. Write, the date, who you spoke to, what about, and followup action item. This is useful when some action agreed to does not happen (no matter who it is) you can leverage that they said that they would do x, y, and/or z. Lack of Followup is great leverage.
- When you review a bill, there are CPT codes associated with the charges, if the charge has been denied by your insurance company, find out why, then go back to the provider of services and see if they can legitimately change the CPT code (sometimes they can) and re-bill. That has helped save me money in a number of circumstances. Each insurance company has slightly different policies and coding. I am beginning to see this as a new pattern.
Wednesday, February 18, 2009
After all my broad medical experiences over the years, including treatment and consumer challenges I cannot simply blindly believe what anyone has to say, which can make me a pain in the ass to some, but my own best friend. It is exhausting and sometimes incredibly frustrating, but, if I don't do it, no one will.
There are so many times, I could just walk away from an insurance debacle or medical procedure decision and, just avoid dealing with them. And boy there are times I have, but I find I have to drag my sorry ass back to the table because I wouldn't be able to stand myself for giving up.
Here is a short story about dealing with insurance, which resulted in a success story, but when you consider the method of resolution I think it is immensely frustrating:
I have found nearly 9 times of 10 with insurance/billing problems the more I simply go back, make another call, find another operator to speak to, I can resolve my insurance/billing issue and have them pay, or get the doctor to write off charges.
Recently on one series of bills, it took 5 or 6 times of sending the documents insurance said they needed/didn't have to find out that they never undated the newer documentation in the system. In and amongst those 6 calls one insurance operator for Aetna, said, Mam, you need to appeal, that is all you can do. I threw my hands up, but several weeks later (2 weeks ago) I tried again, and finally got a reasonable rational result. The result I originally expected which is that insurance should have paid the charge. The bummer is that the result was merely achieved by persistence, nothing really savvy, but not giving up. It is frustrating because it is random. There is often no rhyme or reason and that sucks.
The lesson of the day: Keep on Calling!