You're in the hospital, and doctors have run tests, given you medicine, and performed procedures. You leave the hospital with a long list of costs that aren't covered by your health insurance policy. What do you do? The out-of-pocket costs for the last 12 months in the US were $27,180 for an individual. Or, $55,500 for a family of four in 2022. The good news is that there are ways to lower out-of-network healthcare billings. Thus, save money on services at an out-of-network facility or provider. Here are some tips for getting the best coverage when you get care that insurance won't cover.
According to a report, the US spends $3.5 trillion on healthcare annually. You can save money on your out-of-network healthcare bills if you know how to work with your insurance company. Ensure you also understand how your deductible works.
Deductibles are the amount you pay before your insurance starts paying. For example, say you have a $1,000 deductible that applies to each person in a family. If you visit the doctor for treatment and it costs $500, your insurance will cover the remaining $500. However, not until after the first year's bill clears.
If there is no other way around this issue, consider getting a high-deductible health plan (HDHP). HDHPs often come with lower premiums than other plans. But, they do require higher deductibles upfront. However, getting these waived is possible if certain requirements are met (e.g., using generic medications instead of name brands) is possible.
When you receive a bill from an out-of-network doctor or hospital, the first thing you should do is ask for an estimate. An estimate will tell you how much you will get reimbursed from your insurance company. It will also show how much you'll need to pay out of pocket.
Some doctors and hospitals are willing to provide estimates before treatment begins. If that's not possible, ask if they can give one afterward and what it would include. Including how much will be covered by your insurance. The estimated cost should be broken down item by item. This way you know precisely what the fees are for lab tests or procedures like X-rays, CT scans, and more.
Did you know that most Americans with medical debt have no other debt on their credit report? The best way to prevent surprises is to get a written estimate and explanation of benefits before receiving any treatment. That way, you can ask questions, clarify anything unclear, and make sure you understand what your coverage will be before the work begins.
Ask for a copy of your insurance card so the doctor or hospital can check it against their records. Take this time to verify if there are any restrictions on what treatments will be covered. Or, if there are any other requirements needed from you for them to process the payment on their end.
You should also request a copy of the itemized bill (which includes all charges) from the provider/hospital and insurer. This way there won't be any surprises when it comes time for payment. This is especially true for out-of-network services.
If possible, get this information ahead of time. It may take some extra effort on behalf of those providing care services, but they'll still have enough time available if something unexpected comes up later.
To ensure that you are protected, keep copies of everything. You should have a copy of the bill, a copy of your insurance explanation of benefits (EOB), and the Explanation of Benefits (EOB).
The EOB lists the services received and how much each one was worth. It also details any payments made by your insurer for each service provided. It includes any coinsurance or copayments that were required by your health plan.
The EOB can be confusing because it lists what was paid and what wasn't, but it doesn't explain why certain items were covered or not covered by your insurance company as part of their negotiated rates with providers like hospital chains and doctors' groups who have agreed to accept lower fees than they otherwise would to get patients in their door so they can make more money off them once they're there (i.e., "out-of-network" healthcare billing).
While you can't avoid paying some of the costs associated with out-of-network healthcare, there are options for covering most of your bill. You'll want to check with your insurance company or health plan to see what they offer in reimbursement for out-of-network services.
Your insurance provider can also tell you whether you can go back through your employer if they have an HMO or PPO plan (also known as private plans) available.
Ask them about filing an appeal if your insurance company doesn't help cover any of the bills. If this doesn't work, consider contacting the state's insurance department directly.
Often states have a process where individuals can file complaints against their insurers if they've been denied coverage needed because someone isn't part of their network list but should be covered under another option (such as Medicare).
By taking the time to understand how your insurance company pays for out-of-network healthcare, you can take steps to ensure that you're getting the best coverage for your out-of-network billings. You can do this by knowing what your insurance plan covers and what it doesn't and finding out if you have any options that can help lower costs.
