I am a medical doctor, chairman of a medical school department and faculty in a family medicine residency. I have a blood disorder that requires periodic visits to a specialist in New York City and I recently experienced a kidney stone attack, a surgical procedure and a brief hospitalization locally in Connecticut.
I am employed in Connecticut and I receive my employer-based health insurance from an Insurance carrier located in California. The insurance company partners with a “third party administrator” (TPA) -a business 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 said.
BEFORE you become ill, receive healthcare services and need to assure they are paid for, I recommend the following;
Always try to have your healthcare delivered by an “in-network” “provider” (a doctor MD/DO), hospital, healthcare facility (i.e. outpatient Urgent Care, radiology imaging, physical therapy, counseling center etc.)
Be proactive. Call the number on the back of your insurance card (customer service). Ask them to walk you through what happens when they receive a bill from a provider (of any kind) who delivered health care services to you. This is important regardless of your insurance type– Medicare traditional, Medicare “advantage” (Medicare administered by a national health insurance company), state Medicaid and employer-based (called commercial) health insurance.
Where does the bill go first, what is their role? Then after that and their role? How many “hands” touch the bill? What if it is a doctor’s bill, or from a hospital? Inpatient or outpatient? Or from an “allied health professional (physical therapy, mental health counseling). Let’s not forget drug costs 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 upfront), when it does it apply and when it doesn’t (wellness physical exam, wellness screening-mammogram, colonoscopy etc). What is co-insurance, a co-pay? Most insurers will have a website that offers a “grid” that will outline all of these different situations.
Always make sure that you receive and understand the “EOB” (explanation of benefits) for every bill submitted and processed by your health insurance “system” for a specific date of service (DOS).
Here’s my brief and bewildering story. I received outpatient care on a particular summer date of service in New York City. The care included a doctor’s visit, 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 clinician interpretation.
I didn’t understand it at the time, but my healthcare costs are reviewed both by my health insurer in California and their TPA partner. 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 here 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 approval by the insurer for $11,800 -$1,800 more than the total charges!
This was paid and then recalled.
The provider of care then received a new approval for $14,000!
The insurer EOB states $9,800 was paid, but the provider states 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 for $14,000 less $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?
One provider representative stated we could have a three-way phone call to sort out the issues, but a different provider representative stated they never communicate directly with the insurer! So, I, as the patient ended up receiving a patient account statement for the DOS from the provider and emailing it to an insurer representative. The saga is continuing to this day and is yet unresolved.
My point in sharing this is to emphasize that as a patient enmeshed in insurance issues you must never pay a bill to the provider until you fully understand and accept the reasons for the charges. You have the right to question any charges.
Additionally, do not simply pay charges received from a provider. Often payments to the provider from your insurer will “cross in the mail” 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 part/all is to be paid. I frequently uncover an insurer payment to a provider that has just billed me directly for the same date of service and amount.
In summary, our U.S. healthcare insurance system is fraught 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 healthcare issues and needs at a particularly vulnerable time.
Resilience, persistence and 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 Dept. 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.