You have a medical crisis and you head to the emergency room. You present your insurance card. Doctors and other medical professionals run tests. You’re diagnosed, treated and sent home.
And then the bills arrive.
This is when your health emergency becomes a financial emergency — even though you have health insurance.
Consumer advocates say inflated out-of-network hospital charges are a growing problem as health care providers look for ways to increase revenue.
“It’s a really big bind for consumers and we need a change in the law,” says Dena Mottola Jaborska, director of consumer advocacy for New Jersey Citizen Action. “It really should not be that in-network hospitals have doctors and providers who are not in the network of that hospital.”
Then there are the providers who don’t accept insurance at all.
Of course, when it’s an emergency situation, you may not have much choice. But there are steps you can take to protect yourself and your money from unexpected charges.
BEFORE THE BILL
Start by knowing your health insurance. Ask questions about what’s covered and what’s not.
Also understand how out-of-network charges are handled. It’s common that a provider will charge one price for in-network patients, but they charge a wildly higher price for out-of-network patients.
If you know ahead of time that you will need an out-of-network service or provider, negotiate the fee in advance, says Jacqueline O’Doherty, a certified patient advocate and geriatric care manager with health care advocacy company Health Care Connect.
“The charges applied to out-of-network patients and those who have no insurance are ridiculous and should never be paid,” O’Doherty says. “They are known as the ‘charge master prices’ or the ‘super bill.’”
O’Doherty had one client who needed surgery and was later socked with a $30,000 bill for a second surgeon who assisted with the procedure.
“This was a planned surgery and my client’s mistake was not making sure that the doctor assisting was in network,” she says.
Diagnostic testing also can be problematic, O’Doherty says. For example, when imaging is done, there are usually two charges: one for the actual image, such as an X-ray, and a second for the professional who reads the image. The patient will get two bills, and ahead of time it’s hard to know who will be reading the image — until you receive your “explanation of benefits.” If you can, request an in-network provider.
Jaborska personally had a surprise bill even though she asked questions about her insurance policy.
“My plan covers MRIs and my plan covers kids, but because kids have to be put under anesthesia, that was not covered, so I’m paying the out-of-network price,” she says.
Experts also recommend you research local hospitals to see if they use out-of-network providers. In an emergency, you may not be able to ask questions, but at least you can go to a hospital where your insurance will be accepted for all charges.
AFTER THE BILL
Once you pop your eyes back into their sockets, study your bill closely.
“Hospital bills are notorious for errors, so make sure you received the services you are being billed for,” O’Doherty says. “Request a line item bill and question any charges not understood. Look at the services provided and level of care and confirm that is correct.”
If the charges are correct, but the bill is full of out-of-network charges, get ready to negotiate.
Start by researching the procedure, finding out what is reasonable and customary in your area and negotiate from there, O’Doherty says. Ask your insurance company what it would normally pay an in-network provider for the same service, and use that price. Or, research the Medicare reimbursement amount for the procedure.
To research Medicare pricing for hospital bills, ask the hospital for the Healthcare Common Procedural Coding System (HCPCS) for the service, or ask the provider for the CPT (Current Procedural Terminology). Use the codes to find pricing at the American Medical Association website at commerce.ama-assn.org. If the billing office isn’t budging, see if the hospital has a consumer advocate or ombudsman’s office that will help.
If you’re not sure the charges are correct, you can pay for a medical billing advocate to help. Check out the Medical Billing Advocates of America at billadvocates.com.
If you can’t afford to pay a lump sum, explain your situation to the provider’s billing department and it will probably help you with a payment plan.