Nobody in America likes their health insurance.
The stereotypical image of insurers – as stingy, clutching, covetous institutions, hell-bent on denying as many claims as possible – is perhaps mostly the fault of the health insurance industrial complex. It’s horrible. But since you’re already reading this, I’m probably preaching to the choir when I say: medical billing, in particular, is a nationwide catastrophe. And there’s precious little being done to change the way hospitals and insurers communicate, because most people just accept the devastating bills they receive at face value.
But there are tricks hidden between the lines. Very, very, very well-hidden. Your medical insurance has more policies than you can imagine, each more arcane than the last. Every year, my insurer distributes a new, 500-page manual on the minutia of every policy they offer – as if anyone’s actually capable of reading it. The rules of the game are out there, just not in a format anyone playing the game can understand.
In most cases: it’s best to call and ask an insurance representative for help. But you need to know what to ask for, first. This post should help:
Scenario 1: Surprise, You’re Out of Network
You fell off a bike and got a nasty cut on your cheek. It’s bleeding quite a lot, so you go to the ER. Since the wound is on your face, they offer to have the residing plastic surgeon take a look. The surgeon determines the damage isn’t severe, that glue will be sufficient, and “what the heck, I’m already here, I’ll just glue you up.” Then, weeks later, you’re slammed with a bill for $3,000. It turns out the plastic surgeon was out of network, and the claim’s been applied to your (much larger) out-of-network deductible.
If it happens to you: don’t panic.
This kind of surprise billing is so pervasive; hospitals even have slang for it: RAP’s. Meaning “Radiologist/Anesthesiologist/Pathologist” – or, referring to those clinical disciplines which most frequently see their practitioners working out of network.
Don’t get me wrong – It’s a lousy hand to’ve been dealt. But don’t go pointing fingers. The complexity of the U.S. private insurance system makes it nearly impossible for hospitals to tell which doctors are or aren’t in a particular patient’s network. And the speed at which these specialists must treat patients often necessitates that they skim past details which would otherwise take days to confirm.
If you’re unfortunate enough to have this happen, call the number on your insurance card. When you reach a representative, explain that this particular scenario was out of your control, and that you’re requesting they process the claim under in-network benefits. If you are incapacitated or admitted to an ER, you are not legally liable for the doctor they provided. 99% of the time, your insurer will agree, shift some numbers around on a screen, and boom: with one phone call, your share’s been significantly reduced.
Scenario 2: Stuck With The Bill
You’re not out of the woods, yet.
Even if you go through all of the above, you might still be shocked by the resulting bill. Another problem frequently occurs at this step of the bookkeeping process: the “Balance Bill.”
For example: an out-of-network anesthesiologist who attended your surgery bills Cigna $1,000.
You get the bill and call your insurance to complain. They’re sympathetic, and they approve a “reduced rate” payment of $500 – or what you would’ve paid if the anesthesiologist was in-network. From there, normal coinsurance kicks in. You pay something like 20%, and your insurance pays 80%. So theoretically, you should only pay $100 for this service.
The second, revised bill arrives and – “WHAT? – it’s $600??” There’s a line for your $100, plus the $500 that Cigna “dismissed” during the cost reduction process. If it happens; know that this is not your fault. It’s because that out-of-network doctor who treated you rejected the insurance’s reduced-rate offer of $500.
It’s unbelievably scummy, but humans like money. Doctors are no exception. They don’t care if it comes from you or your insurance – they just want to be paid what they expected. So if you get stuck with one of these “balance bills,” call your insurer again. Explain that the circumstances were out of your control, and that the doctor was not kind enough to accept the reduced, out-of-network rate. 99% of the time, your insurer will help you. It’s in their interest to keep you as a customer, so they’ll just recalculate the claim to approve the full $1,000, and assign you the original 20% share (or whatever your benefits happen to be – 20% is better than most.)
Bottom line: don’t pay any medical bill before you’ve disputed it to the furthest possible extent with your insurance company. If you go to great lengths; to get a human being on the phone, to learn just what to ask for, and how to say all the magic words – our health insurance system works almost as well as any other developed nation’s
