How to Avoid Health Insurance Surprises

Posted on September 13, 2022

Recently a prospective client shared the following with me, “On Monday I was to have surgery for a significant injury. Today, 4 days before surgery, (hospital system) informs me that I have to pay thousands of dollars in coinsurance. Today. Four days before surgery. Not 3+ weeks ago when surgery was scheduled. Why the h#$% would they wait until today, rather than immediately at the scheduling. At least then I could have had the opportunity to skip some other payments and raise money. . . ”

Recently a prospective client shared the following with me, “On Monday I was to have surgery for a significant injury. Today, 4 days before surgery, (hospital system) informs me that I have to pay thousands of dollars in coinsurance. Today. Four days before surgery.

Not 3+ weeks ago when surgery was scheduled. Why the h#$% would they wait until today, rather than immediately at the scheduling. At least then I could have had the opportunity to skip some other payments and raise money for my urgently needed Healthcare.”

Even with insurance, health care costs can hurt. “Americans spend more on health care – both per person and in absolute dollars – than any other country, but we don’t necessarily get what we pay for.” [i]

Each year, Americans spend nearly a trillion dollars – a number that increases every year – out of pocket on health care and health insurance.

What is health insurance exactly? It’s talked about a lot — but how does it really work and why do we need it? Here’s a simple way to look at it: Health insurance is a plan, or policy, that covers a percentage of doctors’ visits and hospital bills. It exists to help offset the costs of medical events, whether they’re planned or happen unexpectedly. Each of us, as a subscriber is responsible for what is not covered.

Health insurance is a contract between you and your insurance company. When you purchase a plan, you become a member of that plan, whether that’s a Medicare plan, Medicaid plan, a plan through your employer or an individual policy.

“Approximately 158 million people get health insurance from their employer or their spouse’s employer, yet many are still vulnerable. The Average family health plan cost more than $20,000 in 2019, 22% high than in 2014 and 54% higher than in 2009. Employees pay more of the rising health insurance costs; 82% of employees had a deductible – compared to 63% 10 years ago – averaging approximately $1,700 per year for individual.”[ii]

“How can anyone shop for a product they have difficulty understanding? It has been said, when it comes to health insurance most Americans don’t have the level of literacy necessary to evaluate options and feeling confident in the decision made.

Especially for the 14 million people who buy individual health insurance on the insurance market place, must choose a plan and use it wisely.”[iii]

As users of medical care services we tend to get hit from every angle – paying for the premiums, deductibles, coinsurance and out-of-pocket maximum or limit.

How to Avoid Surprises

Know before you go. The best self or care partner advocate strategy is to avoid surprises - similar to the recent experience of my soon-to-be client.

When your doctor prescribes any type of test, keep in mind our healthcare system is prone to being “test “heavy footed.” It pays to ask a few questions for whatever your doctor prescribes or recommends, unless you are not concerned about how it could affect your financial bottom line.

1. Ask these simple questions:

a. What will we learn from this test?

b. Will the results be a “need to know,” or “nice to know,” for the next steps in care?

c. How will the information we get from this test be useful to us?

d. Does this test require pre-authorization from my insurance company?

2. Did you have the same test fairly recently? Maybe ordered by another doctor? If so, speak up. It’s possible that prior results can be used and will spare you the time and expense of repeating a test.[iv]

Getting hit with a medical bill you thought your insurance would pay is an all-too-common situation.

There are two ways to combat surprise medical bills, whether they come from an emergency situation or from a healthcare professional: Prevent them in the first place or fight them later.

1. Prevent the Bill. Most surprise medical bills are the result of being treated by someone outside your insurance company’s network of providers. Avoid out-of-network providers whenever you can (although it may be difficult to do in an emergency situation).

a. Before you need to go to an ER, do your homework to determine which nearby hospitals are in your network and use in-network ER physicians. In an emergency, try to go to one of those if time permits.

b. Easier in non-emergences (knee-replacement or other scheduled procedure. Ask the person who is responsible for billing in your doctor’s office for a list of everyone who could conceivably have a role in your care (anesthesiologist, radiologist or anyone else while you’re in the hospital.

c. Call your insurer to make sure these providers are in your network. (Don’t rely on online directories; they can be out of date). If anyone is not “in network,” let your physician know you want only in-network providers.

d. If you need an ambulance, ask to be taken to an in-network hospital (know or have the list handy), though the first responder on board will make the final decision. Best practice is to reserve ER visits for true emergencies, and if it is safe, go in a car.

2. Fight the Bills. When you are stuck with a surprise medical bill, call the provider and your insurance company. Explain that you didn’t realize the care, which was essential, would involve out-of-network providers.

Some physician may accept the insurance payment and forgive the balance. Or the insurer and the out-of-network physician may agree to lower the bill, making it easier to afford.

If you are billed for emergency care or ambulance transport, also ask the first responders or ER doctors to provide documents confirming that you had no choice in how you were transport and the trip was medically necessary.

If all else fails, complain to your state’s health insurance agency. These agencies can’t always help but submitting a complaint might strengthen your bargaining power.

Another option is to work with a Board-Certified Professional Advocate (BCPA). Many of us have the resources and experience to assure a client does not get into an uncovered or out-of-network situation by verifying coverage prior to access. Should a problem have already occurred with unexpected bills arriving, we attempt to negotiate with the insurer to get them paid, or at least lowered.

Questions? Visit www.patientadvocatesofswfl, to schedule a complementary 30-minute consultation.

[i] The Health Care Consumer’s Manifesto: Hot to Get the Most for Your Money: Deborah Dove Gordon, Prager, 2020, p.6.
[ii] Ibid, p. 7.
[iii] Ibid, p.165.
[iv] The Care Partner Project. https://thecarepartnerproject.org.