Have You Checked Your EOB Lately?

Have You Checked Your EOB Lately?

It can cost you money if you don’t review it!

What is it about insurance that makes us run in fear or hold up our hands in frustration hoping to avoid the issue? Is it the expense…the challenge…or the complexity of insurance? Regardless of how you feel about insurance, you should still understand how your insurances works to ensure you receive entitled coverage. For example, do you regularly check the EOB (Explanation of Benefits) statement that your insurance company sends to you following a medical procedure or doctor’s appointment? If you’re not, then you should reconsider and make a habit of checking the statement for accuracy. There could be medical billing errors driving up the amount of money you owe so learning how to read an EOB could be a cost-saving effort on your part.

Why Review an EOB

Each time you receive any medical service, from a simple check-up with your primary care physician to a complicated hospital admission, your insurance company will send you an Explanation of Benefits statement. Your insurer prepares an EOB after a medical provider has filed a claim with your insurance company. While an EOB is not a bill, the statement is just as important since it summarizes medical fees and insurance benefits based upon your coverage. 

You want to check the statement for two very important reasons: 1) Ensure your insurance company accurately applied your coverage against medical services rendered, and 2) Verify your medical provider correctly reported the treatment you received. By familiarizing yourself with the format and the terminology of an EOB, you will be able to confirm whether the statement is accurate.

What to Review in an EOB

Once you know how to read an EOB, you will be able to detect provider billing errors or denials, an overpayment to the provider, and inaccurate out-of-pocket expenses. When errors are caught early, mistakes are easier to address and resolve.

While it is important to review the entire EOB statement, the information in the middle section of the EOB itemizes provider fees and covered benefits. Included in this section are the charges billed by the provider and approved by your insurance company. The statement will show whether you are owed some money, or if you need to pay your medical provider for uncovered costs.

This section should be carefully reviewed by you since there could be mistakes. You want to make sure that your claim was accurately processed, and coverage benefits correctly applied to avoid unnecessary charges. In fact, according to CareCredit, some of the most common billing errors include:

  • Charges for services not received
  • Errors with deductible amounts
  • Wrong amounts charged
  • Services double billed
  • Wrong service dates

If you see errors like these or anything else suspicious, there are steps you can take to appeal a claim.

How to Appeal EOB Errors

When you find errors on your EOB, you will want to file an appeal to your insurance company. The steps to appeal a claim include:

  • Contact the insurance company to notify them of errors
  • Submit a written appeal/dispute to the insurance company
  • Contact the medical provider’s billing department to advise of any mistakes and obtain an appeals form
  • Submit a written appeal/dispute to the provider

It’s important to keep a log of names, dates, telephone, and reference numbers for each insurance and/or provider contact related to your claim. You can handle the appeal process yourself or enlist the services of an experienced health advocate, like Human Health Advocates, which has extensive experience handling health insurance appeals and medical bill reduction.

If you find an error on your EOB and need assistance with disputing charges on a statement, contact Human Health Advocates for help. Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity and affiliated with the Better Business Bureau. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out…..get help…..contact one of our Board-Certified Patient Advocates. We review medical bills and health insurance determinations to locate errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

By Human Health Advocates

Health Insurance Terms Exposed

Health Insurance Terms Exposed

Does health insurance terminology seem like a foreign language to you? Does your mind go blank when you hear words like co-pay, deductible, and out-of-pocket expenses? If you’re nodding your head in agreement, welcome to the club. There are many other people like you who are confounded by insurance and treat it like it’s a necessary evil. However, if you’re letting the insurance company or your medical provider dictate your insurance coverage because you don’t understand your policy, you might be depriving yourself of benefits or coverage you’re entitled to receive. Knowing your insurance policy and its terminology is an advantage you do not want to ignore since it could cost you some precious dollars and possibly medical care.

A simple way to look at health insurance terminology would be to separate it into two categories: 1) Costs; and 2) Medical Coverage. Familiarizing yourself with the vocabulary used in your policy will help you to understand your financial obligations and coverage rights. In fact, starting with the following ten terms might provide you with enough insight to help you manage your health coverage more effectively.

Need to Know Costs

  • Premium – The amount paid for insurance coverage. A premium can be paid monthly or quarterly, or even annually, depending on the preference of the policy owner. The premium is separate from the out-of-pocket expenses such as deductible, coinsurance, and annual out-of-pocket maximum
  • Deductible – The amount paid by the policy owner for a medical service covered by an insurance policy. After the deductible is reached (for example, $6,000 for a single person), the insurance company pays an agreed portion of each expense; until the out-of-pocket amount is reached. Keep in mind that the deductible amount affects an insurance premium. The inverse relationship results in higher the deductible, the lower the premium; the lower the deductible, the higher the premium.
  • Coinsurance – Percentage of covered services that the policy owner and insurer pay. Coinsurance is applied after the annual deductible is has been met. For example, our $6,000 deductible with an out-of-pocket maximum of $7,400, you receive a $ 23,000 hospital bill. Insurance negotiated rate is $8,000. You pay the first $6,000 (deductible). Coinsurance may be 80/20- so the insurer would pay the next $1,600 (80% of remainder), and you would pay $400 (20% of remainder, after deductible).
  • Co-Payment – A fixed dollar amount paid for an in-network covered service. Examples of co-pays include the fee paid for a doctor appointment ($35 for specialist) and prescriptions ($10 co-pay).
  • Annual Out-of-Pocket Maximum – The maximum amount of money paid by the insured over a policy year. The expenses applied usually include copayments, deductibles, and co-insurance. Once met, all covered in-networkservices should be paid by the insurer at 100% for the remainder of the calendar year.

Need to Know Coverage

  • Referral – Necessary with HMO coverage to obtain from Primary Care Physician to see a specialist, have an MRI, and to receive other services.
  • Preauthorization – The primary care doctor or specialist submits a request to the insurance company for preauthorization for certain medical services (MRI, time in a hospital, etc.). Although issued by the insurance company; it still does not guarantee they will pay for the service. However, failure to obtain one in a non-emergency situation (say you have an MRI at your doctor’s office which did not obtain the necessary preauthorization) could make you responsible for up to 100% of the procedure’s cost.
  • Exclusion or Limitation – Exclusion refers to services or supplies the insurance company will not approve; for example, cosmetic plastic surgery may be a policy exclusion. A limitation is a similar clause, setting forth exceptions to coverage, with specific qualifications. Traditionally, limitations are in connection with PRE-EXISTING CONDITIONS. If you have an: “Obamacare” policy you need not worry about these while the Affordable Care Act is law. PLEASE read these clauses CAREFULLY—they can have disastrous results.
  • Denial – Refusal by the insurance company to approve a service or pay a claim.
  • Allowed Amount – Agreed upon amount an insurance company will pay a provider for specified medical services or supplies.

Informed Decision-Maker

 When you are an informed decision-maker, you are better prepared to make smart choices regarding medical care and insurance options. You will be taking care of yourself and your family members health, finances, provided you manage your insurance benefits wisely. However, despite best efforts, sometimes we need assistance. With medical matters, seeking assistance from patient advocates like Human Health Advocates leverages expertise in areas including insurance benefits, medical billing (including hospitals bills), and health insurance coverage denials.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very favorably reviewed entity and accredited by the Better Business Bureau with an A+ Rating. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out and contact one of our Board-Certified Patient Advocates. We review medical bills and health insurance determinations to locate errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

By Human Health Advocates

Know Your Health Insurance Policy

Know Your Health Insurance Policy

Health insurance provides us with a sense of security. We believe it equips us financially to manage health issues from minor to major medical emergencies. But does insurance really secure and protect us? If you don’t know the extent of your medical coverage or your financial obligations, then your sense of protection regarding medical preparedness could be misplaced. You owe it to yourself, your health, and financial well-being to know exactly where you stand with your health insurance. Actually, it’s your responsibility to know and understand your health insurance policy because you should know what to expect and perhaps even demand what to receive.

Insurance Basics

          Having health insurance is not the same as coverage. There are numerous insurance companies, and each offers different types of policies which result in a diversity of coverage limits and costs. Familiarizing yourself with the way your policy works enables you to know the extent and cost of care you, or a family member, are entitled to receive. Also, keep in mind that your insurance policy is a contractual agreement between you and the insurer. If you’re looking for help from anyone to decipher coverage and costs, don’t just turn to the insurance company, but, contact your insurance agent or human resources representative (if you are insured through your employer) to answer your questions. If you need immediate or further assistance understanding your health insurance and financial obligations, then a health advocate could be instrumental in helping you.

 

Plan Options

          The cost of a health insurance policy (i.e., monthly premium) might be the primary criteria that most people use when selecting coverage. Rather than evaluate insurance on its premium fee, instead, it is more sensible to consider the type of health insurance plan you have when evaluating your policy, as well. Plans vary in scope of coverage and flexibility:

  • HMO – Health Maintenance Organization. A good plan if you’re looking for lower out-of-pocket expenses, but little flexibility in the choices of doctors or medical facilities due to limited networks. Selecting a Primary Care Physician (PCP) is required and will issue a referral to a specialist when necessary. There are no benefits for services provided by an out-of-network provider.
  • PPO – Preferred Provider Organization. This plan offers greater flexibility with selecting physicians, and a PCP is not required. Referrals from a physician for a specialist are not required, but some services may require pre-authorization. Doctors, hospitals, and other providers in the plan’s preferred provider list must be utilized in order to take advantage of the lower negotiated rates between insurer and provider.
  • EPO – Exclusive Provider Organization. A combination of HMO and PPO. Like a PPO, doctors are selected from a preferred providers list, and referrals to a specialist are not required. However, there are no benefits for services provided by an out-of-network provider.

Plan Coverage

Next, take a look at your plan to assess whether it meets your personal and family needs. You might already know what type of health insurance plan you have, but if you don’t, take a look at your insurance card for a quick reference. Hopefully, you have a copy of your health insurance policy so you can review your Summary of Benefits. The information in the summary serves as a quick reference guide about your coverage. This summary differs from the Policy Booklet, which is an extensive and detailed explanation of the policy.

The Summary of Benefits presents the scope of coverage concisely and is a useful reference if you want to compare your plan with another one. You’ll be able to assess whether your needs will be met. However, before you start reviewing your plan, you might want to know some key insurance terms:

  • In-Network vs. Out-of-Network:

In-Network: Doctors and hospitals included in a preferred provider list approved by the insurer. These “preferred providers” have negotiated rates, or “allowed amounts,” which provides the insured a discount on covered services.  

Fees for Out-of-Network: Physicians, facilities, or services are not subject to the negotiated allowed amount rates, which can cost you sustainably more.

  • Referral vs. Pre-authorization:

Referrals are provided by a primary care doctor (PCP) to an in-network specialist that will continue care for a specific condition, and insurance company approval is required.

Pre-authorizations are for specific procedures, treatments, or services which may require pre-approval from the insurance company in order to be covered.

  • ACA vs. Non-ACA Coverage:

The Affordable Care Act (ACA), derogatorily referred to as Obamacare Plans, cannot deny coverage based on pre-existing conditions. Which means major pre-existing conditions like diabetes, heart disease/stroke, cancer, COPD, or HIV must be covered under these plans. However, non-ACA plans can and will deny coverage for pre-existing conditions.

The odds of finding one perfect plan for you and your family are not likely. Although it is possible to find a plan that best suits your existing needs, it just takes a little time and research to choose a plan that satisfies cost, coverage, and flexibility. PPOs are good if you prefer the most flexibility, and an HMO or EPO can save you some money on costs. The goal is to assess your specific needs and preferences, then select a policy that is right for your situation.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity and accredited by the Better Business Bureau with an A+ rating. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out…..get help…..contact one of our Board-Certified Patient Advocates. We review medical bills and health insurance determinations to locate errors in providers’ charges and insurer’s processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

4 Smart Steps To Take If Your Medical Bill Goes Into Collections

4 Smart Steps To Take If Your Medical Bill Goes Into Collections

By the time a collection agency contacts you about an overdue medical bill, you might have forgotten about the debt or perhaps even hoped the healthcare provider had overlooked the unpaid account. Unfortunately, financial issues don’t disappear– in fact, they could even get worse. So instead of burying your head in the sand and ignoring the matter, step up and consider a course of action that is in your best interests. Often, it’s the individuals accountable for their financial obligations, which might get a chance at working out a satisfactory arrangement. Whether you’re currently dealing with a debt collections issue now or know someone who is, there are some specific actions which can help you to manage the situation.

With corrective action, you might even be able to prevent the debt from damaging your precious credit. Be proactive and initiate action since this kind of attitude could help you to avoid any surprises that might hurt you financially.

Step 1: Obtain Information

When you first receive a collections notice, you want to verify the debt is correct. Call the collections agency and get as much information about the original creditor, service dates, and amount owed. Minimally, request the name of the original creditor (hospital or provider) and obtain contact information including address and telephone number. Most importantly, request an itemized statement with coding for the amount sought. If the agency doesn’t have this, then you might need to obtain the information from the original creditor. You have the right to collect this information so be persistent with your request. A recent article by Credit.com states that “it’s quite common for collections agencies to make mistakes regarding the debt they claim you owe.” You have 30 days from the date of the initial collections notice to request validation of or dispute the validity of the debt.

Step 2: Submit a Dispute

          If you believe the debt is not valid, you have the right to submit a dispute with a collections agency. In its first communication with the debt holder, a collections agency must not only state they have taken over the account but must also provide the consumer with an opportunity to contest the debt. Don’t delay since you have only 30 days from receipt of a collections letter to file a dispute. While the dispute is under investigation, the collections agency must suspend activity on the account. As explained in a June 2019 article in NerdWallet, an agency “can’t put the issue on your credit reports. If it finds the debt valid, the collector will mail you documents verifying the bill. If not, it will stop attempting to collect the debt.”

Step 3:  Verify Credit Reporting

          Not all collections agencies are created equal. Ask if the agency reports to any of the three credit bureaus (Experian, Equifax, or TransUnion). A collections agency can be either internal or external to the medical provider. There is an important difference between the two, so it’s to your advantage to ask this question. If the agency is internal to the provider, there is a higher probability of certain success with an internal department. You have a greater chance of having your debt removed from collections, correcting errors, and, depending on your circumstances, obtaining a higher discount amount.

Step 4: Negotiate A Resolution

          After you’ve verified the amount is correct, the next step focuses on the handling of the debt. At this point, you might want to consider negotiating a payment plan or a lump-sum discount. However, it’s important to negotiate a manageable amount that is affordable for you. Otherwise, it won’t be possible to make the promised payments. It’s also to your advantage to request 0% interest and confirm the credit agency will suspend reporting to the credit bureaus while you make payments.

You Have Rights

Consumers are entitled to certain rights as stated in the Fair Debt Collections Practices Act. Knowing these rights can be a powerful resource when dealing with collections agencies. A June 2018 article by Consumer Reports points out that “patients need to be able to question bills without damaging their credit rating—and also have reasonable payment options when a bill swamps their budget.” However, medical debt resolution can be a daunting prospect, especially with a complex case. In these situations, getting help from medical billing advocates like Human Health Advocates would provide expertise and peace of mind that can be priceless.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity and affiliated with the Better Business Bureau with an A+ rating. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out…get help…contact one of our Board-Certified Patient Advocates. We review medical bills and health insurance determinations to locate errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

You Snooze You Lose

You Snooze You Lose

We don’t have the luxury of time for hospital fee comparisons when a medical emergency strikes. If we did, we would shop around first for the most cost-effective pricing before setting foot in a hospital. However, reality is different. We’re grateful for medical intervention in times of a health crisis and direct our focus to intervention, treatment, and recovery with little thought of the associated cost. Indeed, financial reality might not hit us until we receive the first medical bill, and it’s then when we become aware of the price tag we pay for medical care.

Reactions such as ignoring a hospital bill or reaching for a credit card should not be your immediate response. Instead, realize that there are some things you can do to manage medical expenses, and as a result, a favorable outcome could be worked out. All it takes is a few thoughtful steps on your part.

Prompt Action

Providers such as medical facilities and physicians must wait 180 days before they can report a medical bill to a credit bureau, but they could send your bill to a collection agency at any time. You do want to follow up with your provider promptly when you receive a medical bill, but before you do this, you also want to have a copy of the Explanation of Benefits from your insurance company (Medicare calls theirs a Medicare Summary Notice – MSN). You need both documents to review for any medical billing errors and accurate deductions. If you see a discrepancy on either of these bills, you only have a limited time for an error to be corrected so don’t delay. If there are errors, don’t forget to report this to your insurance company so the claim can be adjusted. Report and appeal any discrepancies to your medical insurance company within a specific timeframe; fortunately, information about deadlines for appeals are included in the EOB from your insurer.

Two-Way Communication

If you do find an error or have a question about any item billed by a medical provider or processed by your insurance company, contact the medical provider’s billing department or insurance claims office about the error or question. With your provider, request a suspension of the billing cycle or collections effort until the matter is resolved. In fact some states, such as Florida, mandate that providers (in certain circumstances) must suspend the collections efforts until the problem gets resolved. This would be a matter to research if you encounter a medical billing issue or if you work with a medical billing specialist like Human Health Advocates, ask them to look into this for you.

Payment Options

Fortunately, with medical debt, it doesn’t have to be a “pay everything now” proposition. Payment options do exist, however, the chances of negotiating a settlement are greater when the debt is not too old. The same is true of a single lump-sum payment at a reduced rate. A payment plan or discounted fee can be negotiated after the amount owed has been confirmed. Once a payment arrangement has been determined, request 0% interest and ask for the account to remain with the provider until it is paid off. To make sure the debt is not forwarded to a collection agency, document the commitment by having the provider sign a pledge not to report your debt. Your part is to make all payments in a timely manner.

Right to Dispute

If you disagree over the amount charged to you, then file a dispute against the provider to reduce medical bills. For billing discrepancies such as erroneous charges or services, send a dispute letter to the healthcare provider. You would also want to send a separate letter about the disputed charges to your insurance provider. Keep copies of all the documentation that you send since you’ll want to reference it when you conduct a follow-up. You can always contact a medical billing advocate like Human Health Advocates to handle a dispute for you. Whether you enlist the assistance of an expert or handle the matter yourself, your best first course of action is opening the medical bill envelope as soon as you receive it.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity and affiliated with the Better Business Bureau. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out…get help…contact one of our Board-Certified Patient Advocates to schedule your FREE CONSULTATION. We review medical bills and health insurance determinations to locate errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

 

By Human Health Advocates

You Can Avoid Credit Calamity

You Can Avoid Credit Calamity

As a way to manage finances, many consumers opt for medical coverage with high deductibles. While the reduced expense of lower insurance premiums helps to maintain a balanced budget, the financial drain of covering costly deductibles and co-pays in a medical crisis could quickly exhaust a savings account. We don’t always have the luxury of time to plan for large medical expenses; it is often under emergency circumstances, when we’re least prepared, that unexpected and costly hospitalization occurs. The outcome is an outstanding balance which must be paid, however, don’t reach for a credit card. At times like this, when figuring out ways to pay medical debt, it’s helpful to have insight into the medical billing process and its impact on personal credit.

Medical Debt Difference

There have been some recent changes in the way medical debt is reported which in turn, affect how personal credit and credit scores are impacted. First, a required waiting period must be exhausted before medical debt can be reported to a credit agency. A regulation requires Equifax, TransUnion, and Experian to wait 180 days (six months) before an unpaid medical expense can be added to a credit report. Additionally, medical debt is often turned over to a collection agency and, provided the debt is paid in full, the collection agency debt is not included in a personal credit report. This explains why using a credit card to help with hospital bills is not practical. Not only is it advisable to avoid high credit card interest, but more importantly, the special consideration given to medical debt could not be applied.

Worth the Risk?

            Allowing medical debt to remain unpaid is a risky proposition, but according to a June 2018 Consumer Reports article, “nearly 3 in 10 insured Americans had an unpaid medical debt sent to [a] collection agency.” When a medical debt appears on a credit report, the negative effect on a personal credit score can be financially harmful. As a means to manage consumer loan risk, lenders rely on credit scores to predict whether an individual is financially accountable. A low credit score could result in preventing or impacting a financial transaction such as obtaining a new credit card, purchasing a car, or applying for a mortgage. Additionally, landlords and potential employers run credit checks and unfavorable scores could impede getting a new home or even a new job.

A low credit score can also come with a higher price tag. Individuals with poor credit are typically charged a higher interest rate if credit is approved. As reported by the Consumer Federation of America, a new car loan, for example, could add an extra $5,000.00 in interest for someone with a low credit score compared to someone with a higher score. A good credit score would lead not just to obtaining a loan, but also to securing a more favorable rate on a loan. Reducing debt and improving a low score also take time, possibly up to two years, or even longer depending on the type of debt involved.

Plan to Pay

Medical expenses have the potential of growing into large sums since billing charges can include hospitalization, out-of-network bills, doctors’ fees, diagnostic tests, and surgical procedures to name a few. It is a good idea to contact healthcare and insurance providers to verify amounts owed and assess the ability to pay. By making a habit of tracking medical expenses, a person is less likely to overlook any financial obligations and run the risk of compiling unmanageable medical debt. In cases where the amount of debt is overwhelming, even after insurance is applied, medical billing resolution specialists like Human Health Advocates can be consulted to assist with negotiating payment.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity and affiliated with the Better Business Bureau. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out…..get help…..contact one of our Board-Certified Patient Advocates. We review medical bills and health insurance determinations to locate errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

 

By Human Health Advocates

Hospital Fee Transparency More Cloudy Than Clear

Hospital Fee Transparency More Cloudy Than Clear

In the spirit of protecting patients, hospitals began posting their list of charges online in January 2019 (per the Public Health Service Act enacted by the Affordable Care Act). Sounds like a simple thing to do, but consider the numerous services and items hospitals provide: diagnostic procedures, physician consultations, surgeries, treatments, medication, and supplies, to name a few. It gets even more complicated when the scope of difficulty or duration of a surgical procedure or treatment is factored into the equation. Also, there are great variations between various hospital’s pricing—some may charge double what the others do for the same procedure. Imagine how this can affect the ability to have a good understanding of hospital bills. It is this issue, the disparity in hospital pricing, and a lack of desire to make charges known to the public before rather than after treatment which causes confusion surrounding hospital fee transparency and problems for the average consumer. Creating greater awareness of the issues about hospital pricing transparency could help individuals minimize or avoid unnecessary serious financial repercussions.

            Hospital fee transparency is meant to help consumers calculate medical costs to assess a treatment’s affordability. Sounds great in principle, but is it feasible in practice? Would you know what is needed in a surgical procedure and hospital stay? Most likely, you would not know. So how is the average consumer expected to calculate an approximate cost based upon reviewing a list of hospital fees? A hospital price list, known as a “Chargemaster,” can be as short as four pages, but more likely several hundred. On top of this, the information is often not alphabetized or categorized by subject. Some hospitals even use codes which are indecipherable to anyone but themselves. While the list of charges is meant to educate, more often than not, it is a confusing mess. Essentially, a Federal statute was passed—and hospitals complied. However, the statute neglected to mandate posting the information in a manner that is comprehensible by the patient. So, while there are Chargemaster posted, they are essentially useless—as the information they contain is not decipherable.

Advocates of fee transparency comment that the program is new and can be seen as a step towards informing consumers. However, according to a February 15, 2019, article in the Florida Phoenix: “Hospitals have some leeway in deciding how to present the information — and currently there is no penalty for failing to post.”

            With the mid-year mark having passed since the mandated public disclosure, it is possible to analyze the information being provided by hospitals. In its July 2019 issue, The National Law Review raised some problematic issues about the information released by medical facilities:

  • Patient specific variability affecting cost is not included
  • Variances in health plan coverage costs and out-of-pocket expenses and out-of-network bills are not provided
  • Nonexistence of requirements specifying how to format data for public consumption

 

            The success of hospital fee transparency is not just a matter of providing the consumer with clear and concise information, it is also about accomplishing specific goals. The New England of Journal Medicine (NEJM) Catalyst explored the topic of price transparency last year in an article which posited that the efficacy of price transparency depends on the success of meeting the following four goals:

  • Help patients make informed decisions;
  • Enable comparative price shopping;
  • Facilitate affordable care; and
  • Create pressure to reduce pricing.

 

                While the value of posting hospital fees online (in the current manner) is questionable, given the complexity of the pricing, it does expose the random variability and exorbitant differences in pricing among medical facilities. The embarrassment over these disparities could serve as a catalyst for change and motivate some institutions to reconsider their fee structure. Then again, one cannot shame the shameless into doing the right thing. The more light shone on this cloaked pricing information, the greater the benefit to the public. Many have called for further legislation concerning the form and manner in which such information is posted. This could then begin some momentum towards positive healthcare reform in pricing which might stimulate further useful change.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity, affiliated with the Better Business Bureau. Its members are Board-Certified Patient Advocates; specializing in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out…..get help…..contact one of our Board-Certified Patient Advocates at Human Health Advocates. We review medical bills and health insurance determinations, locating errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

By Guest Blogger: Mary Ann Mace

You Can Fight Facility Fees

You Can Fight Facility Fees

Lawmakers have placed pressure on healthcare providers and institutions for transparency with medical fees, however, the information posted online by hospitals is difficult to understand. Assessing an approximate cost for procedures, treatment, and hospital stays remains guesswork, which makes it difficult for consumers to calculate medical expenses in advance. For the time being, consumers might only be left with a defensive strategy as it concerns fighting facility fees.  

How can consumers combat against inflated hospital and physician costs? In a June 2019 Consumer Reports article, there is a choice of actions you could take either before or after incurring facility fees, and it could prove helpful to you:

Medical

Primary Care Doctor: We are all tasked with managing our own healthcare and can no longer expect our doctors to do this for us. However, developing a relationship with your doctor remains an important part of your self-care. This way, it becomes easier for you to ask some of the difficult questions unrelated to treatment. Schedule appointments often, especially if you take medication, and the next time you schedule an appointment, ask the front desk if the practice charges a facility fee. If so, get information on fee structure. Remember, it’s your money and you have the right to know where your dollars go.

Diagnostic Services/Specialists: It’s no secret doctors have a network of other physicians and diagnostic centers they refer to their patients. It’s a lot easier for your doctor to provide a name of a preferred provider he or she has used for years than to look up someone new. Plus, it’s human nature to refer a patient to a resource that has some commonalities. So, if your doctor is associated with a medical center or healthcare services-owned facility, chances are the referral will be too. You’ll need to do your homework and find out the referral’s facility fee, if there is one.

As an added note, in the 2019 article from Consumer Reports, hospitals were mandated in 2016 to notify patients if their doctor, or outpatient facility, had changed ownership to a hospital. Estimated facility fees were also supposed to have been included in these notices. Keep this in mind when speaking with your doctor’s office.

Additionally, you can conduct your own online search if you want to inquire about hospital fees, hospital facility fees, or facility fees. In your browser, type the name of the relevant hospital followed by the keywords “chargemaster” or “billing.” This may help with your hospital bills.

Insurance

Insurance Provider: Uncovering whether there is a facility fee and verifying it’s covered by your insurance provider are two different things. If you’re able to uncover the facility fee charge, then contact your medical insurance provider and ask if the excess fee is covered by your policy. If it is, confirm the amount the policy will reimburse. It might even be worthwhile for you to have a conversation with your insurance provider in advance of any medical care. This way, if you decide to change doctors because of facility fee practices, better to do this in advance of any treatment.

Negotiation: If you find yourself in a situation where you require immediate care and incur facility fees, then you might be able to negotiate the fee with the healthcare provider. Even suggest their waiving the expense, but if this isn’t possible, discuss reducing the amount. As well, you can negotiate with your insurance provider regarding their coverage of the charge. If you don’t feel comfortable negotiating fees, you could consider turning to the services of a medical billing advocate to help you.

Appeal: Additionally, you have the right to appeal an insurance decision. The appeal process can be lengthy and complicated. While you can manage your own appeals, retaining an advocate with medical debt specialization could be advantageous to you. Specialists like Human Health Advocates could not only relieve you of the stress of an appeal, but also offer negotiation expertise.

Keep in mind it’s your decision whether or not to proceed with specific medical care, and you have a choice with where you receive your treatment. Electing whether to proceed with recommended care or go to another provider is your decision. Knowing in advance about any additional costs you might incur can help you to plan financially.

Are you ready to fight facility fees? Contact Human Health Advocates today for a free consultation.

By Guest Blogger: Mary Ann Mace

DON’T LET FACILITY FEES SURPRISE YOU

DON’T LET FACILITY FEES SURPRISE YOU

The next time you’re at your doctor’s office, make sure to request an itemized bill when you leave. Why? You’ll want to scrutinize your doctor’s bill to check for “facility fees,” excess charges which have now become a common practice. The high cost of medical care is common knowledge, but not much has been discussed about facility fee charges which can add hundreds and, possibly, thousands to your doctor’s bill.

Facility fees are the result of hospital-based healthcare organizations purchasing doctors’ practices and outpatient centers. This transforms previously privately-owned entities into employees and hospital-owned treatment centers. So, as a result, when a medical practice is purchased by a healthcare organization, a $500 treatment, formerly performed by a private practitioner for example, could multiply to $1,500, $3,000, or more. So, where can you expect to find facility fee charges? Individual physicians’ offices for one as well as outpatient surgery centers, urgent care centers, and outpatient medical centers.

How to fight facility fees? One of the best ways to fight against facility fees is information. Inquiring about facility fee charges before you get treatment at your doctor’s office or at an outpatient center is one recommendation. Another way to protect yourself against facility fees is with the guidance of a medical billing advocate who can help you with hospital bills. Advocacy firms like Human Health Advocates, which specialize in medical debt reduction, through bill review and reconciliation, insurance appeals, and negotiation, etc., can be among your best resources for assistance in obtaining reductions in your medical debt.

FACILITY FEES CYCLE

Getting sucked into a situation where you could be charged a facility fee can happen unexpectedly through the doctor referral process. If your primary care physician is an employee of a hospital, and you need an MRI, you would be referred to an orthopedist who is a practitioner at a hospital-owned facility. Your MRI would then be performed through the hospital’s imaging services. If surgery is needed, the procedure could be scheduled at a surgical center the hospital owns. All related costs would all be subject to facility fees, which could greatly increase your out of pocket expenses. So, from an estimated $5,000, if treatments had been performed by independent practitioners, fees could soar up to as much as $35,000. On top of this, private insurers might not be willing to pay the added-on expenses.

Don’t Let This Happen to You

Examples of inflated pricing through facility fee charges were reported by publications as early as 2014. One of these appeared in an article presented by The Center for Public Integrity which recounted the following experiences:

  • A surgical center in Iowa City charged $25,872 for the removal of three polyps during a 45-minute stay.
  • In Davie, Florida, a $275 facility fee was added to a $233 doctor bill for the treatment of a dog bite. The 8-year-old girl had received antibiotic gel and a bandage.

Another example documenting the inflated pricing of facility fees appeared recently in a June 2019 Consumer Reports article which reported:

  • A Los Angeles hospital added a $1,300 hospital operating fee for a patient who had received an exam, X-ray, and cortisone injection for a 30-minute doctor appointment

These cases indicate vigilance is needed to avoid these types of fees or a fight against them when they do occur. With only one-third of U.S. doctors categorized as having private practices, that leaves the balance of medical practitioners as employees of hospital-based healthcare organizations. It’s likely many of us will need to know how to fight against facility fees. The next issue of our blog will feature some recommendations which could be useful in minimizing or eliminating some of the surplus cost – saving you hundreds and maybe even thousands of dollars.

Do you feel you have been a victim of inflated pricing? Contact Human Health Advocates today for a free consultation.

By Guest Blogger: Mary Ann Mace

Don’t Pay A Medical Bill Until You Do These 6 Things

Don’t Pay A Medical Bill Until You Do These 6 Things

Medical bills are an inevitable expense and often times patients are ripped off because of mistakes or errors in the bill itself which they failed to recognize beforehand. It is estimated that more than 80% of medical bills contain errors. Additionally, health insurers routinely deny claims erroneously. This only adds to the confusion when trying to decipher your medical bills, explanation of benefits (EOB’s), and how much you should pay your health care provider. However, there are some steps you can take in order to avoid paying a hefty medical bill that you don’t fully understand.

  1. CHECK YOUR INFORMATION

There are many billing errors that occur due to a slight clerical error entered on the claim form submitted to your health insurance company. Even if there is one digit missing from your insurance ID number or your name is misspelled, it can result in your claim being denied- and you being billed prematurely. Many times, claims are submitted to the incorrect insurance carrier. To avoid the hassle, make sure your insurance information on the bill is correct and that the bill has been processed by your insurance company.

  1. COMPARE THE INVOICE TO YOUR INSURANCE EXPLANATION OF BENEFITS (EOB)

When claims are processed by your health insurance company you should receive a statement called an Explanation of Benefits (EOB). The EOB will provide details on how your claim was processed including any deductible and coinsurance amounts, as well as any services that have been denied. Always compare your medical bill to the EOB to verify that the amount on your invoice reflects the amount your insurance company says you owe.

NOTE – Some providers and billing entities are very aggressive. They will send you a bill requesting payment while your insurance company is still processing your claim. Many people pay these bills without realizing that the amount they owe might be substantially less once processed by their insurance company. Look out for phrases such as “Due Now,” “Estimated Amount Due” or “Amount You May Owe.” Don’t get tricked by this sleazy tactic. Call the provider and ask for an invoice showing the insurance processing information. Verify with your health insurer whether you should pay the bill at that time.

  1. REQUEST AN ITEMIZED STATEMENT

It is very common for medical bills to only show a grand total of all items and services without providing a detailed breakdown of them. Errors are often made by the hospital or billing entities that can lead to duplicate or inflated charges– such as $20 for a box of tissues or $75 for a warm blanket.  Therefore, it is important to ask for an itemized statement of the medical so that you can make sure that you are only paying for the services and items provided to you.

  1. CHECK THE CODES

There is billing code (HCPS/CPT) for every medical procedure that is performed by the provider, as well as, diagnosis codes (ICD-10) for every medical condition. These codes are used nationwide in order to inform the insurers directly of what was done and how much it cost. They may appear on your invoice or EOB. There are some instances where coverage may be denied based upon the codes submitted. At times, the insurer may deem the procedure unjustified based on the diagnosis code submitted. Other times, the provider may have submitted the wrong code. Sometimes it is a combination of both. In all cases it is important for you to research the code(s) independently. If it is an issue with insurance coverage, you can request a reconsideration or file an appeal. If it is a provider error, contact them immediately and ask that they review, recode, and resubmit the claim to your health insurer.

Reviewing the codes on your medical bills from practitioners, hospitals, testing centers, laboratories, and other providers is a great way to be sure that your insurance company (and you via co-pays, deductibles, and coinsurance) is only paying for services you received. If you receive statements from either your provider or health insurance without the HCPS/CPT codes, contact them and request an itemized statement with codes.

  1. NEGOTIATE A REDUCTION

Once you have determined that there are no errors in the invoice and that your insurance company has paid its proper share, you might still have a bill that is larger than you can afford to pay at once (and, in many cases, that is just too large PERIOD)! You might try to negotiate a reduction in your medical debt or payment terms that are workable for you.  You can find resources on the internet (Health Care Blue Book, State websites, etc.) that will help assign a value to the services provided that is most common—and thus determine if you were overcharged. This information can be a valuable tool when negotiating with medical providers. Make your financial constraints known to them and ask for a discount. (Typically, paying a lump-sum is more likely to result in an adjustment to the bill. Generally, discounts are not given on accounts with a payment plan).

TIP- Many hospitals and some other providers offer a “Prompt Pay Discount,” if you pay at the time of discharge from the hospital.  They also have financial aid personnel to analyze whether you might be entitled to a discount based upon your income. However, even without a discount, a payment plan can be very helpful— allowing you to spread the payments out over a longer period that is more budget-friendly. If you are negotiating a payment plan remember to ask for zero interest. Also, remember that a medical provider can still report you to any of the three Credit Bureaus (Equifax, Experian, and TransUnion) while you are making payments. This is a detestable practice and should be avoided by having the provider state in writing that it will not report provided you are current in your payments.

  1. TAKE ACTION QUICKLY

Regardless of the size of the bill, it is very important to take care of it as soon as possible. The longer it remains unpaid, the more likely it is to be sent to a collection agency. New laws require hospitals to wait until six months from the date of service before you can be reported to any Credit Bureau. However, if that does occur, it can remain on your credit report for years- likely increasing your costs of buying a home, car, or increase credit card interest rates (nearly anything on borrowed credit).

TIP- You are entitled to a free credit report from each of the Credit Bureaus each year. We recommend that you obtain a credit report every four months. It should be reviewed for erroneous items or incorrect information. If you notice any errors on your report, you can dispute them with the Credit Bureau to have to removed. Learn more here: https://www.consumer.ftc.gov/articles/0155-free-credit-reports

If you are having difficulty understanding your medical bills and/or health insurance Explanation of Benefits (EOB’s), contact one of our Board-Certified Patient Advocates at Human Health Advocates. We review medical bills and health insurance determinations. We negotiate reductions in medical debt from hospitals and other medical providers. We prepare insurance appeals for denied claims. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!