By Jen Wieczner
Just as the health-care system prepares for an influx of newly insured patients, some consumers are facing hefty doctor bills that they weren’t expecting.
As the Wall Street Journal reported this week, the higher costs reflect a bigger trend in medicine. As more hospitals buy up private physician practices, they’re often able to charge higher rates than those doctors’ offices formerly charged—sometimes more than twice as much for the same procedures. Since insurance plans typically cover a fixed percentage of a doctor’s bill, the patients’ out-of-pocket costs often go up as the total bill gets higher.
It’s an awkward situation that can leave patients at odds with both their doctors and the insurance company. But experts say there are options for sticker-shocked patients besides paying the full bill.
Bargain it Down
In the case of a surprisingly high tab for medical work, patients should approach their doctor, says Matthew Tassey, principal of Scribner Insurance and former chairman of the Life and Health Insurance Foundation for Education. When a patient explains that he or she can’t afford to pay a bill, the doctor or hospital is likely to work out a payment plan; the care provider might also reduce its fees, by charging the patient the in-network rate for an out-of-network service, for example. From the doctor’s perspective, even a partial payment can be better than a non-payment or a long dispute. “It’s much less time consuming and aggravating if you can make a deal to pay half of it in cash,” Tassey says. The first step is visiting the doctor’s office manager or the hospital’s finance office and asking to speak with your doctor. Even if lowering the fee isn’t at the doctor’s discretion, “You need an ally on the inside,” Tassey says. “If you can help that doctor be your advocate, you have a much, much higher success rate at getting the bill reduced.”
Review Your Bill
Insurance experts say that as the medical billing system becomes increasingly automated, billing mistakes are common—and if the doctor’s visit is coded incorrectly, the insurance provider might refuse to reimburse it. The bill can clue the patient in to why the insurer did not pay for the procedure, which could help in an appeals process. Many insurance companies also allow patients to track their bill’s processing online and find out if the insurer has paid it yet.
In some cases, an insurance company may refuse to pay some or all of what the doctor or hospital charges, leaving the patient on the hook for even more of the bill. The Affordable Care Act strengthened consumers’ ability to appeal their insurance companies’ reimbursement decisions by requiring an external appeals process through an independent review body, in addition to the internal appeals process that insurers already offered. To appeal, patients have to illustrate why the medical care was necessary or why the insurance plan’s guidelines are outdated. Again, it helps to talk to your doctor first, says Cheryl Fish-Parcham, deputy director of health policy for Families USA, a consumer health advocacy organization: “You definitely need medical evidence to be successful,” says Fish-Parcham.
Get Help Negotiating
Many states now offer so-called consumer assistance programs, funded by grants through the Affordable Care Act, to help people navigate health insurance headaches, including filing appeals with insurance providers. In their first year, the consumer assistance programs recovered more than $18 million for consumers, according to the Department of Health and Human Services. In states that don’t have one of the programs, patients can hire independent health care advocates to help guide them through the appeals process or negotiate with medical providers.
To prevent a future sticker-shock situation, experts advise staying in network whenever possible. If time permits, they add, it’s also worth asking your doctor how much a procedure will cost and if it would be cheaper to get it elsewhere—shopping around can save hundreds of dollars.