Receiving that envelope marked “Statement Enclosed” can send shivers down the spine. It’s a sentiment shared by countless mothers navigating the maze of healthcare costs, one that often feels more perplexing than any parenting challenge. The confusion is real. As a mother, daughter, sister, friend, and physician, I’ve watched the healthcare system take advantage of that confusion. And the anxiety that comes with it is entirely understandable. The abundance of terms and acronym soup associated with medical bills—”deductibles, copays, premiums, HMO, PPO, HSA…”— is overwhelming.
But fear not, this area of healthcare is my jam. I hope to equip you with the right information to turn frustration into empowerment. We’ll explore real-life scenarios, uncover hidden costs, and arm you with the knowledge to become a savvy healthcare consumer.
Why Am I Getting So Many Medical Bills For The Same Visit?
First and foremost, if you have insurance, you can expect to receive TWO types of statements after you receive a medical service: a medical bill from the actual healthcare provider {office, hospital, lab, imaging center, etc.} and an Explanation of Benefits {EOB} from your insurance.
- Your medical bill is essentially a detailed receipt for all the services you or your family received at the visit. For instance, an “Office Visit” line could represent a checkup, and “Lab Tests” would represent any bloodwork or diagnostic tests performed. A medical bill is generated by the healthcare provider to request payment for services given to a patient.
- An Explanation of Benefits {EOB} is a document issued by your health insurance company, not the healthcare provider. It details what services the patient is asking insurance to cover, what the overall costs for the services were, and how much insurance will cover.
Keep in Mind
Your EOB is NOT your bill. You should always compare your medical bills to your EOBs and make sure those numbers are matching up. If not, you need to reach out to the healthcare provider and/or insurance company and please do so in writing {or at least keep a written log of any phone conversations}. Do not pay any medical bill until after you have seen both of these statements.
Can You Explain The Terminology Used On My EOB?
Before we dive into this section, the easiest way to move through this section is to dig up your insurance benefits plan outline to see how this applies to you. It is so important to know what your plan covers and what your expected costs will be. Don’t be blind to this. Be aware of the differences between in network and out of network coverage and benefits.
- Deductible: The deductible is how much you need to pay out of pocket before your insurance covers services.
- If your deductible is $1,000, you pay the first $1,000 of covered services before insurance kicks in.
- Keep in mind that even after meeting your deductible, you may still be responsible for a set portion of the remaining costs {“coinsurance”}.
- Coinsurance: You basically share the cost with your insurance at a fixed percentage.
- If your medical bill is $2000 and your coinsurance is 20%, you pay the first $1000 {deductible}, then you are responsible for 20% of the remaining $1000 {i.e. $200}.
- Copayment {or Copay}: This is a fixed amount you pay for a covered service, like a doctor’s visit or prescription. This may be a set dollar amount {often $15-$30} or a percentage like your coinsurance. Your plan will specify copay amounts.
- You may owe a copay with every doctor visit, every prescription, and even ER visits.
- Out of Pocket Maximum: This is the maximum amount of money you pay out of pocket in a given year. This is reached by adding together all you’ve paid toward copays, coinsurance, and deductible. After this maximum is reached, insurance pays 100% for covered expenses {keyword being covered here}. Unfortunately, your premiums do not contribute to this maximum.
- Premium: Your monthly payment to have medical insurance.
What Are Common Hidden Costs I Should Be Aware Of?
- Watch out for “out-of-network” fees. Visit your health insurance plan’s website to help you confirm if your healthcare providers are in-network.
- Know which hospitals in your area are in-network. If you have a non-life threatening condition that grants you time to choose where to go, make sure you’re sticking in-network. If you need surgery, find a surgeon who has privileges to operate at an in network facility.
- When choosing an insurance plan, pay close attention if your copay is a fixed dollar amount or a percentage. An ER visit can easily rack up a lot of charges and paying a fixed dollar amount, rather than a percentage may be best. However, take into consideration the entire plan and what works best for your family’s medical needs.
- If you have a life threatening emergency are sent to an out of network hospital, you will not be charged out of network fees, thanks to the recent No Surprises Act. However, once your condition is considered “stable” {e.g. you need to be monitored in the hospital for a few days}, this law no longer protects you from out-of-network charges. Transfer out!
How Can I Challenge or Negotiate My Medical Bills?
Did you know you can negotiate your medical bills? I strongly recommend it. Our collective voice against outrageous medical billing is already triggering some tectonic shifts. And there are more tools each day being developed to help you do just that. Consider using tools like FAIR Health Consumer, ClearHealthCosts or Turquoise Health to compare prices for common medical services. This helps you understand the range of costs and identify any potential outliers on your bill. If your bill is too vague to search a service, ask the provider for an itemized bill with the charge details in plain language.
Dealing with billing discrepancies can be time-consuming, and it may require persistence. Keep detailed records of your communications, including names, dates, and summaries of discussions. If discussions with the insurance company and healthcare provider do not resolve the discrepancies, you may have the option to file an appeal. Check your insurance plan for information on the appeals process.
If you encounter difficulties resolving the discrepancies in your medical bills, consider reaching out to consumer assistance programs or healthcare advocates. If you are uninsured, ask for discounts, apply for charity care, and seek financial assistance programs. Some of my favorite organizations that help with this for free are Dollar For and Patients Rising.
…and this all is just the tip of the iceberg of things you can do to control your healthcare costs.
We would love to hear from you! Have you explored any valuable tools or networks that helped your family manage their medical bills? Witnessed parts of the healthcare system that just don’t make sense? Feel free to reach out and share them in the comments below.
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