Managing Your Medical Bills

With the first of the year approaching, and medical bills every increasing, it can be difficult to manage your expenses. These tips can help you know what your responsibility is, keep your costs down, and set up a schedule for payment that works for everyone.

Health insurance is very, very convoluted. It is important to know what your responsibility will be before you enter any medical office. You can use your insurance company's website or call them to get this information. (While it can be frustrating and more time consuming, we recommend calling rather than going on the website to get more detailed and accurate information. On the website, terms can be vague or benefit exclusions not listed.)

WHAT SHOULD YOU ASK?

Am I covered for (surgery, physical therapy, an eye exam, etc)?

If you are not covered for this service, the responsibility for payment will be yours entirely. Be as specific as you can when asking this question: if you are going for something more specialized, whether it is a new test or treatment or something you don't hear about a lot (like TMD/TMJ physical therapy), you want to make sure they aren't lumping a specialty benefit in with a general one.

Is this doctor or facility in-network?

Depending on your insurance plan, you may not be able to see a doctor who is not contracted with your insurance company, or even your specific plan. Even if you are allowed to go outside the insurance's "network," your portion of the costs may be substantially higher by doing so. However, before you cancel an appointment because the provider is out-of-network, ask the billing department. For many insurances, you have to have the name exactly as it is billed to get correct information, and this may the doctor, not the facility, or vice versa.

How much is my deductible, and how much has been met?

A deductible, just like car insurance, is an amount of money that must be paid out of pocket by you before your insurance will cover your costs each plan year. If you aren't sure what amount your deductible is, call your insurance company; they will be able to tell you what your deductible is and how much has been met to date.

If you are on a family plan (or employee + spouse, employee + dependents), you will likely have a family deductible and an individual deductible. You will want to know if your plan is embedded or aggregate. This is just another way that insurance companies are making things more confusing each year!

An embedded deductible means that you only have to meet your individual deductible before insurance starts to pay your medical claims. All claims will also go against the family deductible, and when the family deductible is fulfilled, no one will continue to pay the deductible, even if the individual deductible is not met.

If you have an aggregate deductible, your individual deductible is irrelevant. The entire family deductible must be met before any claims start paying out; there is no lower limit to curb one family member's costs.

Here's a handy illustration to help that make sense!

Using this illustration, you can see that for the embedded deductible plan, any additional medical bills that the woman incurs will not be subject to the deductible even though the family amount has not been met, because she has met her individual deductible. In the aggregate plan, claims will continue to be processed against the deductible even if she is the only one going to the doctor, because the family deductible has not yet been met.

By paying your deductible on claims instead of paying out-of-pocket without insurance, you are ensuring that you are getting the negotiated discount rate that the doctor's office has with the insurance company and not the full billed rates. It also prevents you from paying extra money out of pocket by self-paying now and having other visits go against your deductible later.

Do I need my primary care physician's referral for these visits?

An insurance referral is sent from your primary care physician's office to the insurance company to let the insurance know that you do need this service. If the answer is "yes," call your primary care doctor's office to arrange for a referral and have it faxed to the specialist's office.

Doctor's offices often call a prescription or an order "a referral," but know that this is a very different thing! Even though you have written orders from your primary care or a specialist, if your plan requires an insurance referral, that written order is not enough to get your claims covered.

Do I need authorization for these visits?

Authorization is requested from the insurance company by the specialist's office. While similar to a referral, authorization means that insurance is aware of and approves of your specialty care. Insurance will sometimes only answer the question you ask, so make sure to ask about both authorizations and referrals.

What is my copayment for the service?

A copayment is due up front at the time of visit. This is a set dollar amount per visit and is deducted from the allowed amount paid by the insurance company. Ask if the office or service is considered an office visit or a specialist visit, because the amount may change depending on the answer.

Do I have a coinsurance?

Some plans will not carry a copayment, but instead will have a coinsurance. A coinsurance is a percentage of the allowed amount by insurance. Typically, a plan does not have both a copayment and a coinsurance for a service.

What is my out-of-pocket stop loss?

An out-of-pocket stop loss is the maximum you will pay out of your pocket during your plan year. Depending on your plan, a stop loss may include deductible, copayments, and coinsurance, but it does not include your premium. When you reach this amount, approved services are covered by the insurance company at 100% until your plan resets for the year.

What is my plan year?

Deductible and out-of-pocket maximums reset with the plan year. Many plans reset on January 1, but not all plans do. Knowing when your plan resets can help you plan your routine medical care and finances.

Do I have any benefit limits?

Benefit limits usually come in the form of a number of visits allowed to receive in a given time frame, but might also look like a max that the insurance company will pay for a service (for instance "$2000 for physical therapy", and whether that is seven visits or ninety visits, anything beyond $2000 would be your responsibility), or a timeframe in which to receive the service (such as "90 consecutive days of PT" meaning you can have as many visits as you need of PT but only for 90 days from the date you started treatment, or only one wellness physical per plan year).

Are there any exclusions for this service?

Exclusions are services, tests, or even diagnosis codes that are never covered. A 2D ultrasound might be covered, but not a 3D one. Knowing this will allow you to discuss with your doctor what types of treatments or tests are available that are covered instead of being stuck with a hefty, unexpected bill.

READ THE EXPLANATION OF PAYMENT THAT YOU RECEIVE

The explanations of payment (otherwise known as an explanation of benefits or statement of account, EOP, EOB, or SOA - among many other names, depending on the insurer) can be confusing, but by knowing how to read them, you can understand how much you are responsible for. Knowing what procedures were done and what medications were administered will also help reduce fraudulent or incorrect billing. With this information, you can figure out if you've been overcharged by an office and need to request a refund, or what medical bills to expect. Most insurances take 14-45 days to process bills, so you should receive an EOP not long after that. If you are having trouble understanding your EOP, bring them to your doctor's office and ask them to help you read them.

KEEP TRACK OF YOUR EXPENSES AND RECEIPTS

People and insurance companies make mistakes, and it can be especially hard for a medical office to keep track of your deductible or out-of-pocket if you are having many appointments with different offices and providers. It is more common now than ever that medical offices require payment upfront. Track how much you are being billed for against your deductible and make sure you are not being billed for more than your policy requires. Keep receipts from any copayment, coinsurance, or deductible payments; if someone comes back to ask you for payment, you'll have proof that you already paid.

ASK FOR A PAYMENT PLAN

Most offices are more than willing to set up a mutually agreeable payment plan for your balance. It is illegal for an office to completely waive a deductible, copayment, or coinsurance unless you are experiencing financial hardship (as outlined by federal guidelines), but some offices offer discounts for paying in full, or have interest-free plans. More than 200,000 medical offices in the United States also offer financing through a credit card called Care Credit, which offers deferred interest plans to you, the patient.

If you or a loved one is experiencing pain, don't let finances stop you from getting quality care. Call us at FlexPlus Physical Therapy at 508-650-0060 to schedule an appointment and learn about how we can help you afford your care. Not sure if physical therapy is for you? Ask us for a free consultation! At FlexPlus Physical Therapy, we're With You Every Step of the Way.

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