If you have
trouble understanding your medical bills, you are not alone. Many people are
confused about the bills they receive from hospitals, clinics and medical
your bill should first go to the hospital or clinic. Most have staff available
to answer patient questions. Have your bill in front of you and know your
account number before calling.
Carefully review all medical bills you receive.
insurance policy is a contract between you and your insurance carrier. Any
questions about your health insurance should be directed to your agent or
carrier. Many clinics are affiliated with Health Maintenance Organizations
(HMOs) and may even have a name similar to the HMO. Contact the HMO with
questions related to insurance coverage.
responsible for paying your medical bills. Even though you have medical
insurance, it is common for hospitals and clinics to expect you to pay the bill
in full immediately after receiving services, rather than billing the insurance
company for its share. You then have to wait for reimbursement from your
When paying for
your bill, include the portion of your bill with the account number on it and
also print the account number on your check.
If you are uninsured or using a medical service outside of your insurance’s network, the medical service provider must now give you a good-faith estimate of costs. There is also a new federal dispute resolution process available for individuals who are uninsured, in certain circumstances, such as when the actual charges are much higher than the estimated costs.
New Rules for Out-of-Network Costs
Examine the bills you receive carefully, as recent rule changes may affect your costs. You may receive separate bills for physician services such as anesthesiologist, radiologist or surgeon. The bill may even come from a billing department with a different name than your hospital or clinic. If these bills are from an out-of-network provider for care you received at an in-network facility, they cannot be for a higher amount than your in-network copays, coinsurance, or deductibles for covered services performed at the in-network facility.
Similarly, an emergency facility or emergency provider may not bill you more than your in-network coinsurance, copay, or deductible for emergency services, even if the facility or provider is out-of-network. It is important to note that if your health plan requires you to pay copays, coinsurance, and/or deductibles for in-network care, you will still be responsible for those costs.
If you cannot
pay your bill
and clinics will set up monthly payment plans. Review the paperwork for the
monthly payment plan carefully. Try to negotiate a payment plan. Your hospital
or provider may be willing to accept smaller monthly payments. Understand exactly
what you are agreeing to before signing the contract. Keep in mind that your
payments generally need to be reasonable and you must keep up with your
If you are
having problems paying your monthly bill, discuss it with the medical facility immediately.
If you know before admission that you will have trouble paying your hospital
bill, let the hospital know so you can work something out with them. Some offer
cost-cutting health plans for eligible participants.
Do not ignore
your bills if you cannot pay them. Hospitals and clinics can refuse to provide
care if you or a family member have an outstanding bill.
If your bills
are already past due, you may be turned over to a collection agency. Most
hospitals use an internal collections department before resorting to outside
agencies. This internal collection does not affect your credit rating. It is
very important to work with them in paying off your bill. Be prepared to
provide evidence concerning your current financial situation.
In its advice
to parents of chronically ill children, the American Academy of Family
Physicians recommends the following:
appropriate office quickly.
Keep in touch
with your creditors.
names and phone number of the people you are dealing with.
date, time, and results of your phone calls.
even a small amount, on each bill each month as a gesture of good faith.
If your account
is turned over to an outside collection agency, it usually demands payment in
full. In most cases, negotiations must now be made between you and that agency
– not the medical facility. There are specific laws in Wisconsin that regulate
credit plans and collection practices. If you feel any laws are being violated,
contact the Bureau of Consumer Protection.
companies pay for all or a portion of what they consider usual and customary
fees. This means the amount they see as reasonable for a particular service.
Although each company varies, there is a national standard used as a guide.
Read your policy very carefully to understand exactly what is covered and how
much coverage you have. Buying supplementary insurance or Medigap does not
always help with the uncovered costs. Many times supplementary policies simply
overlap your primary insurance and you end up paying the same out-of-pocket
costs, plus the extra premium.
hospital or clinic and insurance company know if the cost of a service is more
than your insurance will cover. There may be a specific reason your procedure
cost more, or it might be a mistake. If possible, shop around for a
medical facility and compare prices just like you do when purchasing other
goods and services.
review all medical bills you receive. Alert your hospital or insurance company
to any questionable billings or unpaid balances as soon as possible. Keep in
mind the following general tips:
treatment list. Create a log of every test, treatment and medication you
receive. If you do not feel well enough to keep your own record, ask a relative
or friend to do it. Even a limited list will make it easier to decipher your
statements that let you know your medical bills were sent to another source for
payment. These may look like bills, but they should include a statement like
“This is Not a Bill,” or “For Your Records.”
bills as they arrive.
If you have
difficulty understanding the charges on your summarized bill, request an
review your bills for errors. Common billing errors include duplicate billings,
unauthorized charges, incorrect data, duplicate orders, and operating room
times, up-coding, unbundled fees and coding errors. If your name or insurer’s
group number is wrong, the coverage amounts are also likely to be
wrong. If you were in the hospital, see how many daily room-and-board charges
are included. Many plans do not allow hospitals to charge you for your
discharge day, although hospitals frequently do. Additionally, if you went to an emergency room but were not admitted
until after midnight, you should not be charged for the previous day.
Check your bill
for duplicate orders. This is particularly important for medications, lab work,
or hospital room fees. Compare the charges with the doctors’ notes. Hospitals
may bill a patient for a procedure even though a doctor canceled it. Also check
the number of lab tests or procedures you had.
Upcoding is a
practice that inflates the patient’s diagnosis code to a more serious condition
that requires more costly procedures, and can be the result of a simple
clerical error or fraud. To spot it, compare the diagnosis on your doctors’
orders and nursing notes with the charges on your bill.
Upselling is a
charge that is needlessly inflated. For example, a doctor may order a readily
available generic drug for you, but the hospital provides a more costly
brand-name medication without your knowledge or consent, and bills you for it.
Since you are not an expert at determining whether or not a drug is a generic
and may not have been in a condition to make that determination, you are not
responsible for the increased charge.
If you were
charged for several lab tests in a day, for example, call your insurer to see
if the charges should have been bundled under one lower fee. Look for the terms
“kit,” “tray,” and “room fees.” Each of those terms covers charges for several
items, such as gloves, IVs, or sheets. But, you may often find separate charges
for these. Question any medical sounding word that you do not understand; you
may find it should have been bundled with another charge. For example, an “oral
administration fee” is really a charge for a nurse to hand you your medications,
and it should be included in your room-and-board fee. Ask your insurance
carrier if a medical procedure you are having requires prior authorization.
This will make it easier when you file a claim and will avoid the
disappointment when you find out that a procedure is not covered after you have
already had it done.
Do not visit an
emergency room unless it is truly an emergency. It is always more expensive.
Many insurance companies will not pay, or will only pay a portion of an
emergency room bill, if they believe it was not an emergency.
Keep all your
medical bills organized together. It may be helpful to keep them in separate
envelopes with the date of service and date of payment printed on the outside.
Do not transfer
medical debt to a credit card. Most experts warn that this is a poor choice
because the interest rates on your credit card will add significantly to your
debt and transferring medical debt to a credit card may affect your eligibility
for Medicaid. Some medical costs can be deducted from gross income to determine
your Medicaid eligibility. Medical debt on a credit card may no longer qualify
as medical debt.
If you find a
mistake, call your provider, explain the error, and ask someone in the billing
department to make the correction. For each call you make, keep a record of the
time, name of the person you spoke with, and what you were told. If that does
not work, call an account representative or the fraud department of your