Does My Health Insurance Pay For That? « Independent Income Advisors

Does My Health Insurance Pay For That?

Thursday, June 30, 2016 @ 04:06 PM
Author: Peter Young

Mike is my handyman.  For the last ten years or so he has repaired fences, caulked windows, and made other minor repairs around my house.  He has, unfortunately, needed several surgeries over the years, including a number of back surgeries, the most recent of which was this year.  The bills haven’t come in yet, but the explanation of benefit (EOB) forms from his health insurance company have – a whole stack of them.

As of the time of writing, the amounts in the “You Pay” boxes total almost $80,000!

Now this last procedure was the same operation as the last one in the series and performed by the same surgeon.  Mike has the same health insurance as he had before.  But this time the balance billing is wa-a-a-ay more than it was for the last surgery.

What’s the difference?  The multiple EOB’s included services provided by people that Mike has never heard of, but the biggest amount was for a specialist who assisted the surgeon in “navigating” the spine.  The assistant, of course, was not in Mike’s network.  The doctor did ask Mike about the specialist before the operation but Mike was in major pain and medicated accordingly.  I could probably have told him the Martians landed and it would not have registered. Mike cannot remember any discussion about cost.

In addition to the navigation specialist however there were a number of other people who had submitted bills to Mike’s health insurance company that – to the best of his recollection – Mike had never heard of.  Now as previously mentioned, Mike was not exactly at his best just before surgery.  It is possible some of this escaped his attention, but he just can’t believe he completely missed all the people about to bill him.

Unfortunately, situations like Mike’s are becoming commonplace.  The usual response is coaching from the provider to the patient on how to persuade the insurance company to pay up.  If there are complaints made to the media, or the Texas Department of Insurance, the company usually ends up paying a chunk of the bills.  That certainly helps the patient’s immediate situation but who pays for the insurance?  We all do.  The grim math of health insurance is simple: estimate the total amount of claims that are expected and divide that by the number of people buying the insurance.  The result is the premium that insured people pay.

There are defensive measures that a patient and his or her family can take.  Firstly, ask a lot of questions, like: are you in my network; who else is involved in this treatment and are they in my network; how much is this going to cost; if you’re not in my network will you accept the network rate?  In Mike’s case he wasn’t able to think of these questions because of his condition and might not have caught the answers if he had remembered to ask.  If the patient is not able to ask these questions it is vital to have an advocate – a family member or a friend – who can ask for him and record the answers!

Unfortunately, that doesn’t help Mike.  There are however services that will help sort medical bills, verify that they are correct, and negotiate with doctors and hospitals to trim them down.  Adopting these measures however, will help you: directly, if you are on the receiving end of a billing nightmare; and indirectly in lower health insurance premiums!

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