Health insurance billing issues are common and can be confusing at times. When dealing with health insurance bills it’s important to take the following steps:
- Take action
- Organize and review your bills
- Call your insurer and providers
- Follow up
The amount you owe may well be less than what the bills first say. Take notes throughout this process of each thing you think may be wrong, does not seem to add up or that you do not understand. Take notes of all conversations with your providers and insurer.
You should start working on medical bills right away but you should not pay medical bills until after you have carefully reviewed them and what your insurance company says about them.
Organize and review your bills
Get your bills and EOBs together. You will get bills from your medical providers and an Explanation of Benefits, usually called an EOB, from your insurer. Do not pay your provider’s bill until you have compared it to your insurer’s EOB.
Often what seems like a simple treatment will produce more than one bill. For example, when you get a checkup, you might get both a bill from your doctor and also a bill from the lab that did your blood work. If the bills do not give you any detail but only one or two big totals, ask your provider to give you a detailed bill.
Any time you get a bill from one of your providers you will also get an Explanation of Benefits from your insurer. You may get an EOB for each bill or one that deals with several bills at once. The EOB should tell you what your provider is billing, what your insurer will pay and what you may owe. If the EOB does not give you any detail but only totals, ask your insurer to give you a detailed EOB.
Match the bills together with the EOBs and keep them together. Review every detail on every document. Simple typos here can cause major problems. Make sure to review your:
- Name and address,
- Insurance policy number
- Group number
- Provider’s name and address
Check each item on the bill. Things to look for:
- Did you receive that service?
- Does it match your memory and why you saw the provider in the first place?
- Is your provider breaking down one basic thing into many little things?
- Is your annual checkup one charge or 18 charges?
- Did your provider charge you for each little thing and an annual checkup?
Check the number of things and procedures—any chance those are wrong or something got double-billed? For example, when they cleaned your cut, did they use one bottle of saline or three? Did they put in three stitches or seven? Look at the level of care, especially for emergency room care, did your “level one” cut get treated like it was “level three” life threatening?
Compare the bill to the EOB. You should be able to match the items on the bills to the items on the EOB.
Call your insurer. Ask them to help you understand your bill and EOB. Ask them what each charge is for and how they arrived at each of the numbers, like what they will pay and what you will pay. If any charge was denied or not paid in full, ask them why it was denied or not paid in full. Ask them to show you on your Summary of Benefits and Coverage, also called the SBC, why something was denied or not paid in full.
Call your provider and ask for the person who handles billing. Ask them to help you understand everything on your bill. Ask them about each of the items you noted. Ask them to correct them or confirm they are ok.
Be curious and puzzled, concerned and courteous, in your phone calls. At this point, you simply want to know and understand what is on your bill and EOB. Let the representative do the talking.
Take notes during your calls. Write down what was said. Write down the date and time of the call and whom you are talking with. Ask if there is a reference number for the call and ID number for the representative and note them if there are.
Before you finish a call ask:
- If there is anything more they can do to help you;
- If there is anything more you can do; and,
- If there is something they recommend you do.
Review your notes and your memory when you finish a call. Be sure you have everything written down so that you can read and understand it later when you come back to it. You may realize you forgot to ask something. It is ok to call back. You are their patient and customer.
At this point, there is a good chance you will have found problems that need addressing. Your provider will need to issue a new bill and your insurer a new EOB. Mark your calendar and follow up with them to be sure they do and organize, review, and investigate these new documents just as carefully as the first ones.
Eventually, you will arrive at final numbers. You may not be happy with the numbers because you cannot afford them or you may disagree with the numbers because of what your provider billed or what your insurer will pay. If you cannot afford the numbers or think them incorrect or unfair, you can negotiate and appeal.
Negotiate with your provider. First, you may be able to get someone to help you with your negotiations. Ask your provider if there is a medical billing or patient advocate available.
You may also be able to get help from a non-profit credit counseling service. Credit unions, cooperative extension services, and places of worship may also be able to help.
The Illinois Department of Insurance may be able to provide help. Also, if you have a chronic, debilitating or life threatening condition, the Patient Advocate Foundation may be able to help.
Before you call your provider to negotiate, research prices. Have an idea of 2 possible solutions: a lump sum you can pay right now and a payment plan. A lump sum is your best solution. A payment plan is an amount you know you could pay every month for 12-18 months. If your provider agrees to a payment plan, ask them to write it down for you, specifying how much you will pay each month and when the bill will be paid off.
Illinois requires many hospitals to provide assistance to low income, underserved and uninsured patients. Ask your provider what financial assistance is available and how to get it.
In your calls, be calm, concerned, and courteous. Tell the provider your situation and your research and ask them what they can do to help you.
If you believe your insurer is mistaken, you can appeal. Your Explanation of Benefits will have instructions. In some situations, you can get your appeal sped up.
Regardless of the outcome, if you think you are being treated unfairly, complain to the Department of Insurance and the Attorney General, and tell your story to an advocate.
If it is not an emergency, one of the best ways to prevent issues and save on bills is to prepare.
- First, be sure the provider you are going to is in your insurer’s network. Always call your insurer and your provider to confirm they are in network. Many online and printed network directories are inaccurate. Keep in mind that just because your provider was in network last year does not mean they will be this year. Tell your provider you expect everyone who works on your condition to be in network. Before big procedures, write them.
- Second, ask your insurer whether you need preauthorization and get it if you do.
- Third, research prices and providers. A Harvard researcher found that expensive providers are often less effective.
- Fourth, shop around for prescriptions. Check with your provider whether a cheaper or generic drug will work as well. Call your insurer before filling prescriptions. Be sure your pharmacy is in network and the drug is covered. Also, ask your insurer if they offer discounts if you get your prescription by mail. Finally, call around to pharmacies, including those at big discount stores, and compare prices.