Sadly I know firsthand how medical issues can pop up unexpectedly and lead to significant unexpected expenses. Having just gone thru a successful surgery to correct a medical condition, I also know what it’s like to be in the hospital and deal with several different kinds of doctors along the way. All of this costs money, and if not managed correctly can lead to more than the expected cost sharing with the insurance company. It only gets more complicated if other family members on your plan also have medical events and doctor visits that feed to a common deductible and maximum out of pocket (MOOP) expense limit.
First one needs to know their deductible, both individual and family, as well as the MOOP. These numbers need to be known both for network and non-network care. Understand that the MOOP for out of network doesn’t prevent the billing above allowable amounts, set by insurance companies, by the providers. (i.e. $400 charges; $200 allowed; $200 applied to out of network deductible and remaining $200 may be charged by provider as over allowable.) With the information about how much one could owe, then one can plan out the larger expenses.
For most things, one only needs to go to a clinic or doctor’s office for care and many minor procedures. These items will be most cost effective when using only in-network providers. The in-network providers agreed to accept set payment levels from insurance companies to become part of the network. This helps control costs as the contract forbid billing above the insurance company compensation levels. Out of network providers can bill above whatever is allowed by the insurance company. Insurance companies allowable amount levels vary based on a variety of methodologies, but for out of network providers, the amounts only limit how much an insurance company will pay, not how much they can charge and collect from the combination of patient and insurer.
If seeking out institutional care, such as at a hospital, it’s important to ensure the hospital based physicians, which are defined most typically as the ER doc, anesthesia, radiology, and pathology, although the list can be expanded for special circumstances where specialty care is rendered using doctors who work only at that hospital in the specialty unit. Depending on state law and hos the insurance carrier processes claims these physicians can end up processed as in or out of network and when out of network often represent significant costs that weren’t expected by many patients. One last thing to ensure when getting surgery in particular is that the surgeon is in-network because at times regardless of if the hospital is in-network, if the surgeon is not the entire service can end up processed as out of network, costing much more.
If there are no providers in your area who are in-network, a network exception request to the insurer is an option. In this situation one asks that the insurer treat the out of network provider as in network for claims processing, and ideally reach an agreement with the provider to provide services on a specific rate for the care needed. In this case it will also eliminate bill above allowable amounts being owed. Just having the claim processed as in network will not alone alleviate the need to pay amounts above allowable without the added step of a special case rate for the care.
One other cost saving measure is to have multiple procedures performed in one operating session or hospital stay. It will help cut down on some of the duplicative costs associated with each surgery alone. This only applies when two unique surgical procedures are needed at the same time, and both surgeons agree to operate at either the same time or one right after the other. For many procedures it’s not even possible, but when it is possible, it cuts down combined total anesthesia time and associated charges.
Let’s look at an example of an adult going thru diagnosis and treatment of atrial fibrillation (AFIB) with a surgical intervention to rectify the situation which otherwise could not be controlled by a single medicine. First there is the initial doctor, typically a cardiologist, visit and diagnosis of the problem. This can be simple if the afib is chronically present, or require many visits, halter monitors, and even the use of event monitors before a definitive diagnosis is made. Once the diagnosis is made, typically only medicine is used to treat it initially, and when medicine alone controls the afib, that is typically all the treatment needed. Some of the medicine used though can be very expensive so shopping the in-network pharmacies for the best pricing is important. If the afib “breaks-thru” the medicine treatment and appears again a surgical, but not open heart surgery, procedure can be used to ablate the heart to correct the electrical system of the heart correcting the problem.
When having this surgical procedure one needs to see an electrophysiologist –cardiologist who will order some additional diagnostic testing to help prepare for the procedure. Then at the start of the procedure, called an electrophysiological study of the heart the doctor will spend an hour or so looking at all of the electrical impulses around and thru the heart to determine what is not normal. Then, those normal areas are isolated thru ablation techniques. Once the problem areas are isolated they perform various tests to see if the electrical impulses are still going thru and require more ablation or not. This is how other arrhythmias in addition to afib are corrected as well. Ultimately there are some follow up appointments and if lucky ultimately those and the follow up medicine conclude.
In the above scenario there are many providers who will provide and bill for their services. The costs run into the tens of thousands of dollars, at least charges do. Thus, using in-network providers who agreed to fee schedules is important to control your out of pocket costs. Typically one can find an in-network EP Cardiologist at the high volume centers around the United States. These centers will provide a full range of in-network care to affect the treatment and control your costs.
With the costs of the above procedure often approaching an individual’s MOOP, there are some strategies to help control and even spread out some of the costs. First, it’s a frequent requests from various providers that you make a deposit towards your deductible if it is not yet met. This is a double edged sword because often the hospital makes this request but they are some of the slowest to bill leaving the deductible to be processed as paid to other providers instead, and then your money is already tied up. Just say you will pay once the insurance carrier decides who collects the deductible and who gets co-insurance and you can see who is owed what amounts.
For those providers who end up being owned $500 or more, it is worth asking if you can pay it over a couple of months. It depends on the provider and the amount owed how much they will want each month if they are willing to accept a payment plan. The best approach towards payment plans is to ask larger providers such as hospitals to pay them over time versus smaller doctor offices. They understand people can’t typically pay large bills all at once.
One other approach to the large bills, especially when they are at hospitals, is to ask for a discount, maybe 20% for paying a large patient portion all at once immediately when they agree. This allows them to show the account paid instead of receiving various payments still which helps their accounts receivable numbers, so they often agree to a discount. The larger discounts typically come when the insurer already paid a large portion of the claim. This may even be acceptable to physician practices, but it will be a tougher request.
Ultimately all of the various techniques can work towards saving some of your hard earned money when you are getting your health care. Most though are only going to work when receiving extensive care which includes extended hospitalizations and surgical procedures. Give them a try and see if you can save on some of your expenses. The savings can add up.