A single stay in the hospital can result in a bewildering array of bills covering a number of services and providers. Some statements may provide scant details to justify charges while others could include descriptions or codes that make little sense to the average person.
“There’s a lot of mistaken billing out there,” says Tom West, creator of Lifecare Affordability Plan, which helps families make decisions regarding long-term health care.
Billing mistakes could be the result of human error or even fraud, and knowing how to decipher a medical statement can be a money-saving skill. Before paying any medical bill, ask yourself the following questions:
— Do I need an itemized bill?
— Do I recognize all the charges?
— Are the dates and providers correct?
— How old is the bill?
— Are there red flags indicating this is a medical billing scam?
— Has my insurance been billed properly?
— Did I get billed for an out-of-network provider?
— Can I negotiate the balance?
[Read: How to Negotiate Your Medical Bills.]
Do I Need an Itemized Bill?
Some providers send bills that include the total due and little else. That is for good reason, according to one industry expert.
“The descriptions of services provided on a medical bill or statement of benefits are intentionally a little vague,” says Anthony Lopez, general manager of individual and family plans for eHealth, a private health insurance marketplace. “Medical care providers and insurance companies must comply with strict regulations intended to protect the medical privacy of patients.”
While more details probably aren’t needed if the bill is for a single office visit, complex procedures that come with an expensive price tag deserve a closer look. “You should absolutely call your provider and say, please explain these charges,” says Shobin Uralil, co-founder and COO of Lively, a health savings account provider.
Some providers are making it easy to get these details, and you may be able to log into an online account and review a digital bill. However, if you receive paper statements, you’ll need to call your provider to request itemization.
Do I Recognize All the Charges?
Once you have an itemized bill, review everything listed to ensure it matches your records or recollection of the care you received. Don’t automatically assume that the information is correct.
Bills are processed based on a coding system, and those codes are entered by hand, meaning there is always the chance of a worker hitting a wrong key. “You could accidentally get billed for the wrong service,” Uralil says.
However, it could also be an insurance issue that causes a bill to look wrong. “Patients need to be clear about whether the question is related to the health care provider’s bill or related to the payments made to the provider by the insurance company,” says Will Reilly, vice president of marketing for R1 RCM, a revenue cycle management company serving health care providers.
Contact your provider’s billing department with any questions. If you need to dispute a bill, contact your insurer as well. They may have staff who can assist in resolving billing issues.
Are the Dates and Providers Correct?
Beyond looking at the charges themselves, double-check the dates and providers listed. This can be especially important for hospital stays when bills might be generated every time a doctor stops by to check on your status. If you didn’t see a specialist on a particular day, you could be paying more than needed.
“If you feel that the medical care provider is actually billing you for services that you never received, call the medical care provider with your concerns,” Lopez says. “If they insist the claim is correct, call your insurance company to make them aware of the fact and ask them about your next steps.”
[Read: How to Get Help Paying Medical Bills.]
Are There Red Flags Indicating This Is a Medical Billing Scam?
Most billing problems are the result of human error. However, you do need to watch for medical billing scams.
Some scammers might send bills that look legitimate but are for phony services. That’s one reason to carefully check dates and provider names. Other red flags could be a billing address that doesn’t look familiar, requests for sensitive information such as a Social Security number or phone calls claiming to be from Medicare. Just as the IRS won’t call people, Medicare representatives typically don’t contact patients via the phone.
How Old Is the Bill?
It could take longer than you think for a medical bill to arrive in your mailbox. Many insurers require providers to bill them in a timely manner, but that could still be months. Once a bill is sent to the insurer, health care providers have to wait for payment before billing a patient for the balance.
While your bill winds through this process, it’s possible that your deductible has been met in the meantime. In that case, the insurance company will pay the entire amount. If you get an old bill, double-check the status of your deductible and if it’s been met, ask your provider to rebill the insurer.
Has My Insurance Been Billed Properly?
If a bill is higher than expected, confirm your insurer has been billed correctly. “You want to be sure the insurance is reported on the bill you receive,” West says.
In addition to your bill, you should also get a separate statement from your insurance company for each bill they receive. “This document confirms that a claim has been submitted to your plan by a medical care provider,” Lopez says.
Compare your itemized statement to the explanation of benefits provided by your insurer to confirm they were billed for the same services. If a service is on your statement but does not appear on the EOB, contact your provider to request your insurer be billed.
The use of technology and online solutions can make this process easier for consumers, according to Reilly. “With a digital approach, patients should be able to manage everything from a consolidated view,” he says. “This puts bills from hospitals, doctors and other clinicians in one place alongside the EOBs so patients can clearly see charges, insurance payments and out-of-pocket costs.”
Did I Get Billed for an Out-of-Network Provider?
Surprise billing, or balance billing, occurs when a patient believes they are getting care from an in-network provider, but the health care professional or facility is actually out of network. For instance, a person might be admitted to an in-network hospital, but a specialist providing services is not part of the network. As a result, an insurer may decline to cover some or all of their charges.
In recent years, many states have enacted laws regarding surprise billing, but their provisions have varied widely. In January 2022, the federal No Surprises Act went into effect to provide consumers standardized protections nationwide.
Among the law’s provision are bans on surprise bills for emergency services, out-of-network cost-sharing for emergency and some nonemergency services and out-of-network charges for out-of-network providers who work in an in-network facility. Consumers who believe they have been incorrectly charged for these services can call the government’s No Surprises Help Desk at 1-800-985-3059 or file a complaint online.
[Read: How to Negotiate With Debt Collectors.]
Can I Negotiate the Balance?
Don’t assume you have to pay the total listed on a bill. Hospital collection rates are not great, particularly for emergency room visits, and providers may be happy to offer a discount in exchange for a cash payment. If you do negotiate a bill, be sure to get the agreement in writing.
It’s even better if you think to negotiate the price before an elective procedure since that’s when you have the most leverage to secure a reduced rate. “The best defense against unexpected bills is to ask beforehand,” West says.
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Questions to Ask Before Paying Any Medical Bill originally appeared on usnews.com
