We hear the horror stories time after time. Someone has received necessary medical attention and then gotten stuck with a bill their insurance company has refused to pay. The doctor or hospital informs the patient that she’s on the hook for it and the payment is often beyond budget.
Take Brittany Cloyd’s story for example, which was shared and published by Vox Media.
[Brittany] was doubled over in pain when she arrived at Frankfort Regional Medical Center’s emergency room on July 21, 2017. “They got me a wheelchair and wheeled me back to a room immediately,” said Cloyd, 27, who lives in Kentucky.
Cloyd came in after a night of worsening fever and an increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.
The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist.
A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it. Her insurance company denied the claim – saying an ER visit for ovarian cysts was unnecessary and inappropriate.
– Vox Media
How was she supposed to know?
Or like Scott Kohan’s story, another eye-opening story shared by Vox Media.
[Scott] who woke up in an emergency room in downtown Austin, Texas, with his jaw broken in two places – the result of a violent attack the night before. Witnesses called 911, which dispatched an ambulance that brought him to the hospital while he was unconscious.
“The thing I remember most was my lips were caked in blood and super dry,” Kohan says. “My head was throbbing, so I touched the top of my head, and I could feel staples there.”
Kohan called for a nurse, who explained that he would need jaw surgery that night. In the meantime, he tried to check whether the hospital — Dell Seton Medical Center — was in his insurance network.
“I was on my iPhone lying there with a broken jaw, and I go on the Humana website and see the hospital listed,” Kohan says. “So I figured, okay, I should be good.”
Except he wasn’t: While the emergency room (where Kohan was seen) was in his insurance network, the oral surgeon who worked in that ER was not. That’s how Kohan ended up with a $7,924 bill from the oral surgeon that his health plan declined.
– Vox Media
How could he have known that?
These stories, and many others like them, are part of a project by Vox to uncover, document, and report on such cases. These stories are real. And there are a lot of them.
So the questions become, “How do you lower the risk of receiving an unexpected, high dollar medical bill?” “What can you do if you find yourself in a similar situation?”
Here’s a practical list our team has put together to help you lower the risk:
- Know your insurance plan (backwards and forwards) before you actually need to use it. Be knowledgeable about the can’s and can not’s, the do’s and do not’s, and the will’s and will not’s. Know your stuff.
- When possible, have an advocate with you at the hospital. Drag along someone you trust who will ask good questions and help you make good decisions.
- Never sign any kind of financial responsibility or insurance waiver before getting the necessary pre-authorizations unless absolutely necessary due to the urgency of your situation. If you need life-saving surgery or treatment right then – go ahead! Sort it out later. BUT – if you are presented with a waiver that requires you to assume full responsibility for payment simply to accommodate the hospital or doctor’s schedule – wait it out. Time slots frequently open up unexpectedly and you may be pressured to move ahead for the sake of the efficiency of the provider. Don’t do it. Get your pre-authorization.
- As a bit of an aside, be aware of ambulance costs. These can sneak up on you. There should be a line item in your insurance plan. Uber may be smarter. Read more about it in this article by Kaiser Health or in this summary article by Frugal Nurse.
But let’s face it, sometimes it doesn’t matter how careful you are, as the stories above illustrate. Other times you are simply situationally incapable of making careful, informed decisions. And a whopping, unexpected medical bill is the result.
What to do then?
- Don’t take it at face value. Contact your insurance company. Explain the situation. Argue like crazy. Ask about their appeals process. You’re the customer.
- Know about the resources in your state that advocate and represent you. Consumers Union – an advocacy group within Consumer Reports – has a great online tool to help you know about agencies in your state that will help you appeal and negotiate high, unexpected medical bills.
- Many states have laws on the books to prevent this kind of behavior by insurance companies. More legislation is on the way across the country. How about your state? The Commonwealth Fund may be able to help point you in the right direction.
- Haggle. No kidding – haggle and negotiate with the originator of the denied claim. Very often, they are more than willing to reduce fees and work out payment plans with you. They just want to get paid.
Lastly, Bankrate.com has created a guide to help you prevent debt from surprise healthcare bills. You can check out their guide here.
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