I am a physician, department chair of a medical school, and professor in a family medicine residency. I have a blood disorder that requires regular visits to a specialist in New York City and recently experienced a kidney stone attack, a surgical procedure, and a brief hospitalization local to Connecticut.
I am employed in Connecticut and receive my employer-based health insurance from an insurance company located in California. The insurance company partners with a “third party administrator” (TPA), a company that processes insurance claims for the insurance company. The insurance company is part of a much larger insurance organization with separate branches located in many states. Enough talk.
BEFORE you get sick, receive health services and need to make sure they are paid for, I recommend the following;
Always try to have your health care delivered by an “in-network” “provider” (an MD/DO physician), hospital, health care facility (i.e., urgent outpatient care, radiology imaging, physical therapy, counseling, etc.)
Be proactive. Call the number on the back of your insurance card (customer service). Ask them to explain what happens when they get a bill from a provider (of any kind) who has provided you with health care services. This is important regardless of your type of insurance: traditional Medicare, Medicare “advantage” (Medicare run by a national health insurance company), state Medicaid, and employer-based (called commercial) health insurance.
Where does the bill go first, what is its function? Then after that and your role? How many “hands” touch the ticket? What if it’s a bill from a doctor or hospital? Inpatient or outpatient? Or from an “allied health professional (physical therapy, mental health counseling). Let’s not forget the costs of medications and even durable medical equipment (crutches, wheelchair, walker, etc.)
Understand what it means to have a deductible (money you/the patient/legal guardian must pay up front), when it applies and when it doesn’t (wellness physical, wellness screening mammogram, colonoscopy, etc.). What is a coinsurance, a copayment? Most insurers will have a website that offers a “grid” that will outline all of these different situations.
Always make sure you receive and understand the “EOB” (explanation of benefits) for each bill submitted and processed by your health insurance “system” for a specific date of service (DOS).
This is my short and puzzling story. I received outpatient care on a particular date of summer service in New York City. The care included a visit to the doctor, a series of blood tests, all directed to different laboratories in the same hospital system. Some could be run through a machine and others required a doctor’s interpretation.
I didn’t get it at the time, but my health care costs are being reviewed both by my health insurer in California and their partner TPA. However, the actual check is cut by the branch of my insurer based in the state where I receive my care, in this case, New York. Now this is what you better get used to, my bill had 20 separate line items and a total charge of $10,000!
The saga begins with the insurance company approving $11,800 -$1,800 more than the total charges!
This was paid for and then remembered.
The care provider was later re-approved for $14,000!
The EOB from the insurer states that $9,800 was paid, but the provider states that it was never received.
The provider then received $5,580 from the New York State insurer.
Since the approval was for $14,000 ($4,000 more than the charges and the $5,580 the provider received, the provider billed me $14,000 minus $5,580… or $8,420 even though remember, the original charges were $10,000!
How is an individual patient supposed to untangle such a mess?
A rep from one provider said we could have a 3-way phone call to resolve issues, but a rep from another provider said they never contact the insurer directly! So I, as a patient, ended up receiving a patient statement for the DOS from the provider and emailing it to an insurer representative. The saga continues to this day and is still unresolved.
My point in sharing this is to emphasize that as a patient mired in insurance issues, you should never pay a bill to the provider until you fully understand and accept the reasons for the charges. You have the right to dispute any charge.
Also, don’t just pay charges received from a provider. Oftentimes, payments to the provider from your insurer will be “mail-crossed” with a bill from the provider to you. Always check with your insurer or TPA to understand how your insurer is processing the provider claim and when/if a portion/full is due. I frequently discover an insurance payment to a provider who just billed me directly for the same date of service and amount.
In short, our US health insurance system is riddled with convoluted workflows that can frustrate even the most sophisticated and knowledgeable patient. This, in turn, creates tremendous stress that can further complicate a patient’s health care issues and needs at a particularly vulnerable time.
Resilience, persistence, and the determination to advocate for yourself with all parties involved will help you successfully navigate this system and support your well-being.
Howard A. Selinger MD is chair of the Department of Family Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University. He is also on the faculty of the ECHN family medicine residency in Manchester.