Monitoring the financial transactions that accompany any medical challenge can require vigilance, but the long-term benefit of remaining financially secure is worth the extra effort.

By Sarah O’Leary

When you are in the throes of a major medical event, the last thing you want to do is manage the quality and the price of your care. Yet by taking some key steps throughout the process, you will save yourself time and energy in the long run.

Dealing with a medical event is intimate for the patient and his or her family. Your trust of your healthcare provider(s) is crucial, and the lines between the value of quality, intimate care, and the business of that care can be blurred. Outside our direct relationships with doctors, nurses, and other caregivers, however, is a $2.8 trillion industry that profits from consumers.

It is important to objectively and unemotionally manage your insurance company and your medical providers’ billing departments. Insurers can unfairly deny claims or services that are covered by the policy or unfairly terminate a policy. Billing departments may attempt to “balance bill” or get the patient to pay beyond what the insurance company believes is warranted and what the patient owes in deductible and co-pays if they believe they should have been paid more by the insurance company with whom they have a contract.

It is critical to carefully check every document you are asked to sign, every bill, and the insurance company’s Explanation of Benefits (EOB) so that you may remain fiscally healthy and receive all the coverage and care you deserve as you proceed through treatment.

Managing Your Insurance Company

Do not give away your power by feeling a need to trust your insurance agency. The business model of insurers is to take in more money than they pay out in claims. Never assume you are “in good hands” or that a cute little gecko will be there for you. Your insurer is not “like a good neighbor” but is actually a corporation. These messages are simply emotional bridges created by advertising agencies to give consumers a sense of intimacy with an insurance brand. We should expect that the insurance company will honor the parameters of the policy we pay for, no more or no less. You are best served not to let anything cloud your objectivity.

Check and double-check your EOB (the documents you receive from your insurance company explaining your policy’s coverage in relationship to your medical bills). Just because the insurance company says it will not pay part or all of a claim doesn’t mean it is being fair or accurate. Know your policy, and make sure your insurance company is holding up its end of your contractual obligation.

Managing Visits, Tests, Procedures, and Billing

Ask your healthcare provider (doc­tor, therapeutic center, hospital) to e-mail or mail to you all the pa­perwork you will need to complete prior to an office visit. You should take the time to read it carefully. Take special notice of any verbiage that says you will be legally respon­sible for any/all charges not coveredby your insurance company. We ad­vise our clients to cross those lines out or add, “provided the tests/pro­cedures are medically necessary, not the responsibility of the in­surer, and their pricing fair market values.” You don’t want to give any healthcare provider a blank check.

When you receive a bill from the doctor’s office or hospital, read it carefully. Industry experts say that up to 40 percent of medical bills contain errors. For anything beyond a simple physical exam, ask for an itemized list of the services provided. Oftentimes doctors and hospital billers use a billing template for certain tests and procedures, and you might accidentally get charged for something you did not receive.

When you are going to enter into a nonemergency medical event, it pays to ask in advance for a written estimate of all costs. Beware of add-on costs such as “facility fees.” The healthcare providers might be shocked when you ask for a detailed estimate upfront, but don’t be afraid to ask. Would you shop at a grocery store that did not put prices on its products? By at least trying to get pricing upfront, you are less likely to be overcharged.

Know Your Options for Appeal

Neither your insurer nor your healthcare provider have the last word in terms of the quality of care you receive and the price you pay for it. You can file an internal appeal with either group; and, depending on how you received your insurance, you can also ask for an independent arbiter to review your case. In most states you can file an actionable complaint with the state’s insurance board. In every state you can file a complaint with the Better Business Bureau. In the event you still feel that you were treated improperly, you can hire legal representation to have your case heard in a court of law.

Be smart and be well!

Five Quick Tips for Managing Your Insurance Company

1. Don’t “love” your insurer! Love is an intimate, emotional response to what is a strictly business relationship between you and your insurer. Remain objective at all costs.
2. Monitor your policy monthly to make sure it is current and that your healthcare providers are still included in its network.
3. Never accept the insurer’s EOB as gospel. Check the documents carefully against the parameters of your policy and make sure the EOBs themselves are accurate based on the care you received.
4. Appeal all denials of services or claims for medically necessary treatments—and ask your healthcare provider for help if you need to prove medical necessity.
5. When overwhelmed, get an experienced, trusted friend or hire an independent professional (not someone assigned to you by the hospital) to help you!

Five Quick Tips for Helping Manage Your Healthcare Providers

1. Ask for detailed upfront pricing for all nonemergency tests and procedures from your provider’s billing department. Beware of facility fees and other hidden costs.
2. Request that all forms be sent to you in advance of nonemergency treatment so that you have time to study them and check with your insurance company regarding coverage.
3. Do not pay any bills sent to you by your healthcare providers until you receive the Explanation of Benefits from your insurance company.
4. Experts estimate that up to 40 percent of medical bills contain errors. Take time to check every bill thoroughly!
5. If you are feeling overwhelmed by paperwork, call a trusted friend or hire a professional (not someone assigned to you by the hospital) to help you.

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