Health Insurance Navigator

By Lisa Zamosky

The topic of medical bills is of growing importance, with no apparent end in sight to the many ways in which consumers are being overwhelmed by health care costs.

I talked last week with Dan Rodrigues, CEO of Kareo, a medical billing software company based in Irvine, CA. What’s interesting about his perspective on medical bills is that his company works with doctors’ offices to help them do a good job of billing insurers for their services to keep their medical practices afloat.

According to Rodrigues, many of the surprise medical bills patients face are mirror images of those doctor’s offices also confront daily. He says there are a handful of common errors both doctors and patients make when it comes to medical bills, and he offers these five tips for avoiding sticker shock following your next visit to the doctor.

1. Plan ahead: According to Rodrigues, it’s technically the responsibility of the staff running a doctor’s front office to understand how insurance networks operate, whether they are in or out of your carrier’s network, and how different medical services will be billed and paid for. They should then be able to turn around and clearly explain those details to you, the patient.

The reality, however, is that staff are often overwhelmed by a dizzying array of insurance plans, and unfortunately, many aren’t clear about which insurance plans the doctor accepts. What’s more, each individual plan – even those offered by the same insurance company – has different negotiated rates. It’s common, therefore, for the person who greets you at the front desk to get co-pays wrong and give incorrect information about what is or is not covered.

The solution: “We recommend both staff and patients do their homework,” Rodrigues says.

Send a copy of your insurance card to the office days in advance of your visit. Make sure to include detailed information about your plan, including the group number and insurance ID number. Ask the doctor’s office to check into your eligibility before your visit and to call you with any concerns.

2. Do it yourself: You can leave all the legwork to your doctor’s office staff, but that would be a mistake. At the same time they’re checking into your insurance eligibility, you should be doing the same. Confirm for yourself that you’re covered for the services you need. Ask your insurer whether you will owe money at the time of the visit, and if so, how much. That way you can compare notes with your doctor’s office.

3. Confirm network status: It’s been said many times before, on this blog and elsewhere, that one of the best ways for patients to protect their wallets is to confirm – before your appointment – whether the doctor, hospital or clinic from which you’ll be getting care is in your insurance company’s network of contracted providers. You need to call the doctor before your visit and ask if he or she participates. Never rely on the list your insurer provides in a handbook or on its website. They are more often than not out of date or just flat out wrong.

“If the patient knows ahead of time [that the doctor is out of their network] they might wait to find an alternative provider that is in network,” Rodrigues says. In-network doctors are likely to cost you a lot less money for the same service.

4. Don’t delay: According to Rodrigues, the bills produced by a doctor’s office, as well as the explanation of benefits (EOB) your insurer sends, can be filled with cryptic codes and are difficult to understand. That often leads people to take a head-in-the-sand approach to their medical bills.

“What happens is they figure they don’t need to pay the bill and they sit on it and wait until they get calls from provider’s office. Having that discussion when you’re on your second or third collection call isn’t good for anyone,” Rodrigues says.

As soon as you receive a bill you don’t understand, pick up the phone and call your doctor (or hospital) and ask for someone who can walk you through the details and clarify what you owe.

5. Use new online pricing tools: New online pricing services help patients figure out in advance of a doctor’s visit how much it should cost.

In addition, take a look at this earlier post, which talks about how insurers are changing the way they figure what to pay for out-of-network costs. Find out if your plan will use usual and customary or Medicare rates when reimbursing you for care. The answer could make a huge difference to your wallet.

Your turn: Have you been surprised by a medical bill? If so, please, share your experience and what you did about it in the comments section.