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.
The fundamental problem is most medical billing systems were designed with third-party payers such as insurance companies in mind. "The patient portion was really an afterthought," according to Kent Ivanoff, CEO and co-founder of VisitPay, a medical billing solution that consolidates bills and provides a single statement each month for all members of a family.
While services such as VisitPay are working to demystify the billing process for consumers, many patients continue to receive confusing statements in the mail. 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?
-- Is this bill for a COVID-19 test?
-- Can I negotiate the balance?
Do I Need an Itemized Bill?
Some providers send bills that include the total due and little else. 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.
"Ask for an itemized bill for a substantial bill or when it is more than expected," says David Vivero, CEO and co-founder of Amino, a health care financial wellness platform that employers can integrate into their workplace health care benefits.
Some providers are making it easy to get these details. "If you get a digital bill, you can click on that and drill it down." says Florian Otto, co-founder and CEO of Cedar, a platform that provides medical billing services. 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. "Patients should not accept anything that is either wrong or they don't understand," Otto says.
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. "A hospital will charge you for every time someone pops their head into your room," says Sharona Hoffman, professor of law and bioethics at Case Western Reserve University in Cleveland, Ohio.
If you didn't see a specialist on a particular day, you could be paying more than needed. Contact the billing department to dispute any charge for care you do not believe you received.
Are There Red Flags Indicating This Is a Medical Billing Scam?
Most billing problems are the result of human error. "Oftentimes, we're victims of honest mistakes," Vivero says. 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. "The longer that a provider waits, the more likely they can just bill your insurer," Vivero says. By waiting, your deductible is more likely to be met, meaning the insurance company will pay the entire amount and a provider won't have the hassle of collecting payment from the patient.
Many insurers require providers to bill them in a timely manner, but that could be as long as 12 months, according to Ivanoff. Then, once a bill is sent to the insurer, health care providers have to wait for payment before billing a patient for the balance.
It's not unusual for it to take several months before a patient receives a bill, and providers often have until the statute of limitations runs out to collect on an outstanding debt. "That can be six, seven years depending on state law," Ivanoff says.
Has My Insurance Been Billed Properly?
If a bill is higher than expected, confirm your insurer has been billed correctly. "Sometimes, the bill is literally wrong, (and) that might be a problem with insurance," Otto 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 Explanation of Benefits, contact your provider to request your insurer be billed.
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.
"Some states have tried to implement safeguards against (surprise bills)," Hoffman says. If you receive one of these bills, check with your state's insurance commission to determine what, if any, consumer protections are available in your area.
Is This Bill for a COVID-19 Test?
Insurance coverage for COVID-19 testing has evolved in recent months. "I think they were fairly liberal in the first three months of the pandemic," Ivanoff says. At that time, insurance companies may have been covering all costs for COVID-19 viral and antibody testing.
However, some insurers have tightened their rules since then and will only cover testing if pre-authorized or under other certain circumstances. If you have been asked to pay for COVID-19 testing, confirm that your bill was processed under your insurer's coverage policy at the time of the test.
Can I Negotiate the Balance?
Don't assume you have to pay the total listed on a bill. "At the very least, try to negotiate with providers," Vivero says. He notes that 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.