The Confounding Conundrum Of Unexpected Medical Bills

It can be frustrating to receive a bill, especially when you have insurance and expect to be covered. However, there are several reasons why you might be receiving a bill from your healthcare provider. Firstly, your insurance plan is a cost-sharing agreement, and insurance companies often require you to cover all costs until you reach a specified amount, known as a deductible. Once you meet this deductible, the insurance company starts contributing to your medical costs for the rest of the period, which is usually a calendar year. Additionally, insurance companies typically cover preventive care, such as check-ups and vaccinations, but for other services, you may be billed until you reach your deductible. It's important to understand the terms of your insurance plan, including copayments, deductibles, coinsurance, and maximum out-of-pocket expenses, to avoid surprises when receiving medical bills.

Understanding your insurance coverage

Know the Basics of Insurance

Insurance is a contract between you and your insurance company. It's a cost-sharing agreement where you pay a certain amount, and the company covers the rest for the services specified in your plan. Understanding this agreement is essential to know your financial responsibilities when seeking medical care.

Understand Common Insurance Terms

Insurance has its own language, and knowing these terms will help you navigate your policy:

• Deductible: The amount you pay for covered health services before your insurance company starts paying.
• Copayment (Copay): A fixed amount you pay as your share of the cost for each medical service, like a doctor's visit.
• Coinsurance: Your share of the cost for a covered health service, calculated as a percentage of the total cost.
• Premium: The amount you pay monthly or annually for your insurance coverage.
• Network: The group of doctors, hospitals, and suppliers your insurer has contracted with to provide healthcare services at a negotiated rate.
• In-Network: Providers with a contract and negotiated rates with your insurance company, resulting in lower costs for you.
• Out-of-Network: Providers without a contract with your insurance company, leading to higher costs for you.
• Explanation of Benefits (EOB): A statement sent by your insurer explaining the medical treatments and services paid for, the fees, and your responsibility.

Know What Your Plan Covers

Different insurance plans have varying levels of coverage. Some may not cover certain prescription drugs, mental health care, or specific procedures. Familiarize yourself with the covered services listed in your policy to avoid surprises.

Understand Cost-Sharing Mechanisms

Your insurance plan may use deductibles, copays, and coinsurance to share costs with you. Knowing how these work will help you estimate your expenses:

• Deductibles: You may need to pay a certain amount out of pocket each year before your insurance coverage kicks in.
• Copays: A fixed dollar amount you pay each time you receive medical care, such as $20 for a doctor's visit.
• Coinsurance: Instead of a fixed amount, you may be required to pay a percentage of the total cost, such as 20% of the bill.

Stay Informed About Your Benefits

Keep track of your EOBs and billing statements. Review them carefully to understand what services were provided, what your insurance company paid, and what you may still owe. Contact your insurance provider if you have questions about coverage or costs.

Choose In-Network Providers

Using in-network providers can significantly reduce your out-of-pocket expenses. Out-of-network providers may not have an agreement with your insurance company, resulting in higher bills for the same services.

Review Your Policy Regularly

Insurance policies can change over time. Stay updated with any modifications to your plan to ensure you understand your coverage and can take advantage of any new benefits.

Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is a statement from your health insurance provider that details the costs of medical care or products you've received. It is not a bill, but it does show you how much you may owe.

The EOB is generated when your healthcare provider submits a claim for the services you received. The insurance company sends you an EOB to clarify:

• The cost of the care you received
• Any money you saved by visiting in-network providers
• Any out-of-pocket medical expenses you'll be responsible for

The EOB will show you:

• The date of the medical care
• What medical services were performed
• How much the insurance company is paying
• How much you might owe

It is important to check that the information on the EOB is correct. For example, you should make sure that you are not being billed for a service you didn't receive or being billed twice for the same service. If there is a mistake, you should call your insurance company.

You should always save your EOB until you get the final bill from your healthcare provider.

Statement from the doctor's office

Dear [Recipient],

We are writing in regard to the bill you received following your recent visit to our clinic. We understand that insurance and billing procedures can be confusing, so we would like to clarify the situation and outline the next steps.

Firstly, it is important to understand that your insurance plan is a cost-sharing agreement between you and your insurance provider. In general, insurance companies cover the costs for preventive care, such as check-ups and vaccinations. For other services, you may be required to cover all costs until you reach your deductible, at which point the insurance company starts contributing to the covered services.

After your visit, our office submitted a bill, also known as a claim, to your insurance company. This claim included a list of the services provided by our clinic during your appointment. The insurance company then reviewed this information and determined how much they would pay for each service, as outlined in your insurance plan.

It is possible that you received an Explanation of Benefits (EOB) from your insurance company, which details how they handled the claim. Please note that an EOB is not a bill, but it can help you understand what your insurance company is paying for, what they are not paying for, and why.

Our office may have also sent you a statement, which outlines the charges for the services you received. If you received this statement before your insurance company paid us, please disregard the amounts listed, as these will be adjusted based on your insurance coverage.

Once we receive payment from your insurance company, we will send you an updated statement with any remaining balance that you may owe. At that point, you can proceed with the payment options outlined in our previous correspondence. If you have already paid in full, we will reimburse you for any overpayment.

If you have any questions or concerns about the billing process, please don't hesitate to contact our office. Additionally, if you have specific inquiries about your insurance coverage or the amount you owe, it is best to reach out to your insurance company directly.

Thank you for choosing our clinic for your healthcare needs. We value your trust and aim to provide transparent and accurate billing information.

Sincerely,

[Doctor's Name/Clinic Name]

Surprise medical bills

In the US, the No Surprises Act (NSA) was passed in 2020 and came into effect on January 1, 2022, to protect patients from surprise billing. The NSA protects those with group or individual health insurance coverage and limits the amount of out-of-pocket expenses for emergency services from out-of-network providers or facilities. It also limits out-of-network cost-sharing for emergency and some non-emergency services and out-of-network charges and balance bills for supplemental care provided by out-of-network providers at in-network facilities.

Even before the NSA, some states in the US had implemented their own legislation to protect patients from surprise medical bills. For example, Georgia passed the Surprise Billing Consumer Protection Act in 2020, which came into effect on January 1, 2021. This Act provides a mechanism to resolve billing and payment disputes between insurers and out-of-network providers and establishes a fair and equitable arbitration process to handle such disputes. Virginia also introduced similar protections, effective January 1, 2021, which protect consumers from getting billed by an out-of-network healthcare provider for emergency services at a hospital or for certain non-emergency services during a scheduled procedure at an in-network hospital or other healthcare facility.

If you receive a surprise medical bill, you can:

• Contact the provider or facility and tell them that you believe you have been wrongly billed. Request that your bill be lowered.
• After contacting the medical provider, get in touch with your insurance company for assistance.
• If you are still unsatisfied, you can file a complaint with your state's relevant office or agency, which will review your case.
• If the medical provider and your insurer are still unable to agree on an acceptable payment, they can enter arbitration to resolve the dispute.

It is important to understand your insurance coverage and what you are expected to pay for healthcare services. After receiving treatment, your doctor's office will submit a claim to your insurance company, which will then send you an Explanation of Benefits (EOB) detailing what they paid for and what you may still owe. Your doctor's office might also send you a statement, which shows how much they billed your insurance company and any balance that you may need to pay.

Insurance claim disputes

Disputes with insurance companies are often a result of a disagreement over the amount due on a bill, the amount a company paid on a claim, or nonpayment of a claim. These claims can be resolved, but it may be a complex and confusing process. Here are some steps to help you navigate an insurance claim dispute:

Understanding Your Insurance Coverage

Before filing a claim or disputing a decision, it is crucial to understand the terms of your insurance policy. Review your policy documents to determine what is covered, what exclusions may apply, and whether there are any specific conditions or requirements for filing a claim. Understanding your coverage will help you assess whether the insurance company's decision is justified.

Communicating with Your Insurance Company

If you have questions or concerns about a bill or a denied claim, start by contacting your insurance company. Ask them to explain their decision and provide clarification on the coverage provided by your policy. It is important to maintain open communication and carefully review any documentation they provide, such as an Explanation of Benefits (EOB).

Gathering Documentation

When disputing an insurance claim, it is essential to have thorough documentation to support your case. This may include photographs, receipts, medical records, witness statements, and any other relevant evidence. Organise and keep copies of all documentation related to your claim, as you may need to refer to them throughout the dispute process.

Involving a Third Party

If you are unable to resolve the issue directly with your insurance company, you may need to involve a third party. Consider contacting your state's insurance department or a government agency that oversees insurance companies. They can provide guidance and assist in resolving disputes. Alternatively, you can seek the help of an independent appraiser or a public insurance adjuster to provide a professional opinion on your claim.

Mediation or Alternative Dispute Resolution

If the issue remains unresolved, consider pursuing mediation or alternative dispute resolution (ADR) processes. Mediation involves a neutral third party who facilitates discussions between you and the insurance company to reach a mutually agreed-upon solution. ADR includes other processes, such as appraisal or arbitration, which can help settle disputes without going to court.

Seeking Legal Advice

If all else fails, you may need to seek legal advice and consider taking your insurer to court. Consult with a lawyer who specialises in insurance disputes to discuss your options and determine the best course of action. They can guide you through the legal process and represent you if litigation becomes necessary.

Frequently asked questions