health care costs

Posts Tagged: health care costs


4 Things to Know about Statements & Medical Bills (to Keep from Overpaying)

If you ever received a medical service and used your insurance, you have surely received a lot of paper in the mail or electronically. Do you know the difference between all of them? The most important distinction is between Explanation of Benefits (EOBs) and statements from your provider. Why? One is a true bill, one is not.

So what’s the difference? An Explanation of Benefits (EOB) is your insurance company’s way of informing you that they know you’re covered, they looked at the claim your provider sent them, and here’s how much they calculate you’ll owe. It’s an FYI.

At the same time, your insurer sends this information back to your medical provider – along with their payment to them. Then, it’s your provider’s turn to take that info and – voila! -put together a bill for you.

Now that you’ve got the sequence of events, that means a few things for you:

1) An EOB is only an FYI. To be certain about the amount you owe, wait for a bill from your provider to verify the amount.

2) EOBs usually arrive before a bill. So when you see a new EOB, you now have a sense of what to expect. If you receive a bill before you get an EOB, check to make sure your insurance paid and you aren’t getting billed for the full amount.

3) At the end of the day, your provider is who you owe. Don’t send money to your insurance company for an EOB!

4) You could owe less. Your provider may further adjust the amount you owe with additional discounts, but you should never pay more than the EOB shows. Your provider cannot bill you for something the insurance company did not pay if it wasn’t described as your responsibility in your EOB.


Why Did my Health Insurance Deny My Claim!?

No! You expected your health insurance to cover a service, and then you get the dreaded letter that it’s been denied. Why do claims get denied and when does it actually matter (that’s right, sometimes it doesn’t matter)?

Your health plan might refuse to pay for a service or treatment you received for many reasons. It’s good to know whether it was denied because of the services themselves OR because of how your provider submitted it. Why is this important? Because in the first case, you’ll probably be responsible for paying the claim. In the second, you won’t be.

Here are some common reasons claims get denied where you could be responsible:

  • You didn’t get a referral or prior authorization when it was required
  • The service isn’t covered by your plan
  • You already used up your benefits for the service (like a cap on the number of physical therapy visits per year)
  • You went out of network when you have an HMO
  • Your insurance wasn’t effective at the time of the service

Don’t confuse these situations with those where a claim (or a portion of a claim) was denied because of how your provider submitted it to your insurance. This happens surprisingly frequently.  It might be that:

  • Your doctor didn’t submit the right billing code to your insurance plan
  • Your doctor didn’t submit the claim in the timeframe your insurance required
  • The service was actually covered as part of another claim or set of services
  • The claim is a duplicate that was already paid

You might see these things show up on your EoBs, or Explanation of Benefits–the statements you get from your health plan just informing you about your coverage (the ones that say “This is Not a Bill”). Just know that if your provider made a mistake submitting a claim, or your insurer found that it had already been paid for, you’re not responsible!

So before you panic, look into the reason for the denial. And if you believe you were billed unfairly for the cost, you can always appeal the decision. All health plans have to honor a process of reviewing claim appeals from their members.


65 Free Preventive Care Benefits to Take Advantage Of

It’s been said that nothing is free – even with health coverage.

But if you’ve already paid your premiums, now is the time to take advantage of all the 100% covered benefits.

Health plans are required to completely cover 16 free preventive services for adults, 22 for women, and 27 for children. That means you won’t pay any co-pays, co-insurance, or deductibles on any of these 65 services.

Here’s how you can make the most of those free benefits.

Get your basics done.

Aim to get an all-around profile of your health with screenings or wellness counseling.

  • Breast & colon cancer screenings
  • Diabetes, blood pressure, cholesterol, STD, HPV, & depression screenings
  • Vaccines for flu, pneumonia, measles, polio, meningitis
  • Annual check-ups for women
  • Counseling to quit smoking, lose weight, stop drinking, or on HIV and STDs, domestic violence, or breastfeeding.

Here is a complete list of services.

Tell your doctor

The next time you see your doctor, mention that you want to take advantage of your preventive care benefits.

If your doctor has record of you asking about them, they’ll not only be able to start you off, but they’ll see it in their notes whenever you come in and follow-up with you.

Basically, put it on the record: You’ll be more likely to get things done when someone else is part of the plan.

Know the limits

“Free” doesn’t necessarily mean, “always free.” The key is the word “preventive.”

If you’ve had a past medical history that now requires care that would normally be free, it doesn’t count.

For example, if you had a breast cyst, a mammogram would no longer be considered a preventive care benefit.

The same thing happens if the service is aimed at diagnosing a specific illness: if your doctor orders a colonoscopy because you’re having stabbing abdominal pain, the preventive care benefit wouldn’t apply.

Check your bills

For your health plan to treat a claim as a free preventive benefit, it needs to be coded with the right medical billing codes.

For example, a mammogram for a breast cancer patient will have a different code than a mammogram for a perfectly healthy woman.

Doctors and insurance companies make mistakes, so you should review your bills to make sure you weren’t charged. If you’re billed for a service you think should be free, call your health plan or ask your doctor about it.


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Do you Need Supplemental Health Coverage?

With more and more people signing up for high deductible health plans, supplemental health policies have also become more popular. According to America’s Health Insurance Plans, high deductible health plan enrollment has grown by over 18% since 2011. Since these plans have deductibles of anywhere from $1,200 to $8,000, a supplemental policy to pad your plan can look very tempting.

Supplemental plans can either help pay your deductible and out-of-pocket costs, or they can pay out a lump sum of money either at one time or each day that you qualify for benefits.

The plans can be pretty inexpensive—as low as $12 a month for an individual and $20 to $30 a month for a family. But the benefits can vary drastically so make sure you know what you’re buying.

Considering supplemental health coverage? Ask these questions.

How much would an emergency would cost you?

Add up your deductible and the out-of-pocket you would owe for a few days in the hospital. Of course, you can’t be sure without knowing the actual costs, unless your plan has only fixed co-pays. But you can estimate: assume any major event would cost well over $10,000—how much would your co-insurance be?

Getting a rough idea will help you understand how useful a supplement might be.

Would you have other (non-medical) costs?

In an emergency, you might find yourself with other financial hardships such as lost wages, living expenses, or transportation costs. A supplemental policy can cover these expenses. Usually, the plan pays you a cash sum and you can decide how to spend it. One advantage of this type of policy is that it can help cover expenses that are not HSA-eligible.

What are the plan’s benefits?

Will the benefits cover enough of your likely costs to be worth it? A typical accident or injury plan may pay out $250 for each day you’re in the hospital, while a critical illness policy will pay a lump sum if you are diagnosed with cancer or have a stroke. If your day to day costs would far exceed the daily benefit, the policy is not worth the money.

How do you qualify for benefits?

It’s important to read the fine print here. A policy may only start paying benefits if an illness or injury reaches a certain degree of severity or may limit the days of benefits it pays. It may also pay much lower benefits for more common diseases—the times your most likely to need it. For example, one consumer was told his policy would pay $5,000 for cancer, but in reality, the $5,000 was only for internal cancer (breast or lung) and skin cancer was paid at $100.

The bottom line is, weigh the costs and benefits of supplemental health insurance carefully. If you have a typical health plan, you probably do not need an additional policy. But if you have a very skimpy or high deductible plan, you’re more likely to find a supplement to be helpful.

And most importantly, remember that these plans are meant to be what the name suggests—a supplement—and not a replacement for full health insurance.


How Does Your HSA Compare?

Wondering how your HSA stacks up compared to others?

Are you saving enough or spending too much?

We decided to look at Simplee users as a group to see. As of the end of June 2012, the average Simplee member had $1654 in their HSA. This was up from $1385 at the beginning of the year, but not quite as high as the average of $2235 the previous fall. That seems to suggest many people are saving up as the year goes on and then paying out their deductible by the end of the year.

The good news? Most consumers seem to be saving more than they’re spending. For the first half of 2012, Simplee users contributed an average of $2289 each quarter to their HSA and only distributed $1903 per quarter.

So how much should you have in your HSA? Well, just like any savings account, the more the better—but of course, within reason. You obviously don’t want to tuck away so much money that you can’t afford your other bills. But at the very least, you want to have enough to cover your deductible.

The average American has $1490 in their HSA (as of 2011, according to the Employee Benefits Research Institute), so it looks like Simplee users are doing a bit better than average. Way to go!

To track your HSA transactions and manage your expenses easily, log in to Simplee.


Tricks to time your health care to get the most out of your plan

Just about every health plan has features that are tied to the calendar year: deductibles, annual benefit limits, and FSAs (Flexible Spending Accounts). And through just a bit of planning, you can save a lot of money on health care.

It’s all about timing. Try these tricks for getting the most out of your benefits.

Go on a deductible-spree:

Once you’ve met your deductible, it’s a good time to get any major, expensive services as well as other routine or elective care. That’s when your plan will pay out its full benefits. If you meet your deductible mid-year, try to plan any other health care services for that year. Waiting until the following year means you will have to pay the deductible all over again.

Watch benefit limits:

If you are getting repeating services – such as physical therapy, counseling, or chiropractic visits, don’t lose track of how many you’ve received. Many plans have an annual limit so stay within this number and know when the benefits roll over.

Get Free Dental Benefits:

Dental plans that offer free check-ups and cleanings usually use one of two methods to calculate your benefits: the calendar year or every 6 or 12 months. Find out what the rules are for your plan, and then pay attention—you know your dentist likes to send out reminder postcards and that Simplee will email you about unused benefits. Don’t ignore these!

Also keep in mind that some dental plans cover procedures up to a dollar maximum for the year. If you are close to reaching the max near the end of the year, but still need a root canal, you might want to wait until the next year for better coverage.

Spend down your FSA: Flexible Spending Accounts are use-it-or-lose it at the end of the year. Most turn over at the calendar year, but some plans use a fiscal or academic year. Make sure you know the date your plan renews, and spend down your account in time. If you find yourself with a large balance near the end of the year, you can always stock up on staples such as bandages or contact solution.

Do you have more tricks that you’ve used to squeeze the most out of your plan? Share with us!


Health Premiums Might Rise. But You’d be Buying Better Stuff.

There are a lot of rumors and stories about health insurance premiums rising because of the health reform bill. Are they true?

The short answer is, it depends on who you are, and no one really knows. But some new rules will keep your premiums from exploding in cost, while also providing better coverage.

If you have employer coverage, it’s hard to say. Some think employers might stop offering health insurance and instead let their employees buy their own on the health insurance exchanges—which could be more expensive–or could be cheaper, depending on the employer.

If you have individual coverage and a pre-existing condition, you’ll probably see your premium decrease.

If you have individual coverage, and you’re pretty healthy, you might see your premium increase. But not simply because insurers want to raise prices—because your coverage will be better.

Here’s why: Right now, most of the health plans that exist are not up to the standards of the plans that will be offered in the health insurance exchanges in 2014—the place where most people will be shopping for coverage. The cheapest, most minimal plan that will be allowed in the exchange, a bronze plan, is better than the average plan offered right now.

So if you currently have the super-cheap plan, in 2014, it probably won’t be offered in the exchange. The lowest level plan will likely cost more than that super-cheap plan, but it will offer better coverage. And that means lower deductibles and cost-sharing for you (Remember, premiums aren’t the entire picture—what good is a health plan if you pay for it every month but you’re constantly paying out-of-pocket?).

So that’s one way health reform might increase your premiums. But there are also some ways it might hold them down:

First, almost 60% of people who will purchase insurance through the exchanges will be eligible for a subsidy. If you earn less than 400% of the Federal Poverty Line ($44,000 a year for an individual, $88,000 for a family) you’ll qualify for a sliding scale subsidy.

(How much? Punch your info into this Subsidy Calculator to see what you’ll get.)

Second, another part of health reform prohibits insurance companies from raising premiums by more than 10% unless they can justify to a board of experts that the increase is reasonable. While this might not keep premiums from rises, it will definitely prevent huge increases.

It’s a close call. The Congressional Budget Office estimates that with health reform, the average annual premium for an individual plan will be about $5,800 in 2016. Without the reform bill, it would be closer to $5,500.

It’s hard to say whether you’ll come out ahead on your premiums after health reform goes into full effect. But coming out ahead as far as good reliable coverage? That’s more certain.

Has your health insurance premium increased lately? Tell us about it.


Insurance Companies Are Courting You

Have you noticed your health insurance company getting a little warmer and friendlier lately?

A trend of insurers “putting customers first” has definitely begun. Whether it will translate to real savings for consumers is the question.

In a great, recent blog in the New York Times, author Tanzina Vega talks about how insurers have been ramping up their PR campaigns, trying to combat the reputation the industry has picked up for bad service over the years. Now, many of the largest companies are trying to put more of a focus on their customers, in a variety of forms: discounts and rewards for losing weight or quitting smoking, consumer-friendly cost comparison tools, or just slick campaigns branding themselves as not just insurance, but family friendly health care solutions.

So this got us thinking. How do health insurers rank when it comes to customer satisfaction? Are they really that bad? Are they getting better?

We looked up ratings from the American Customer Satisfaction Index—a national scoring of major service sectors (ranging from 0 to 100). Turns out Americans’ opinion of health insurance companies has generally been getting better over the last 10 years. Though they are still near the bottom of the pack with an average score of 71: just a bit worse than the US Postal Service, which averaged 73, but still lagging far behind internet retail, at 81. However, most of us think calling our health plan is better than calling the airline we’re flying.
To compare other industries, visit

Why the big push to please consumers now?

Much of it relates to the health reform bill, which is expected to make almost 20 million Americans newly eligible for private insurance coverage. So what better way to start competing for new customers?

So we might expect the score for health insurance companies to continue to rise, but is customer satisfaction the same as good health care coverage? Or could it be a distraction from increasing out-of-pocket costs? Reward programs are nice but when it comes down to needing a surgery covered, they’re no substitute.

We have yet to see, but one thing seems promising: insurance companies are paying more attention to you than ever before.

Tell us what your health plan has done for you that you love, and how you’d rank them on the Customer Satisfaction Survey.


Questions to Ask When… You First Get a Medical Bill

You get a medical bill in the mail, or a notification that there’s a new claim in your Simplee account. Now what? Here are the questions you should be asking.

1) What were you charged for?

It seems obvious, but make sure you were charged for the right services and procedures—and that you were not charged for services that may have been ordered, but then cancelled. If the bill doesn’t clearly list the services, ask for an itemized bill. And if there are items you don’t understand, ask the provider to explain. If you want to be an extra rock star at checking bills, look up the CPT codes to make sure they match the service you received. The codes are not always shown on a bill, so you may have to request them from your provider.

2) What are the dates of service?

Are the dates correct? This is especially important for hospital stays. Most hospitals do not bill you for the day you were discharged if you left in the morning. For smaller services, such as lab tests, you may see a date sometime following the visit where they were ordered.

3) Who paid what?

The bill should break down the cost of the claim into at least three figures: the total charge or fee, any discounts or adjustments, and the amount your insurance covers. Your attention should be on the cost after any discounts and the portion your insurance covered.

4) Does “who paid what” line up with my benefits?

This is where you either need to pull out your benefits documents, call your insurance company, or log in to your Simplee account. Find out:

     • Have you have met your deductible? (the Simplee dashboard will show you)

     • Was the provider in or out-of-network?

     • Were the right co-pays or co-insurance applied?

     • Was there something that should be covered but was not?

If you’ve asked all these questions and you’re still wondering if the bill is correct, it might be time to call the plan or a professional billing advocate.


Avoiding Big Bills in a Medical Emergency

No one really wants to be thinking about health plan rules in the middle of a family emergency. But then again, no one’s ever excited to receive a big unexpected bill for a trip to the ER—especially when it could have been avoided.

The key is to be prepared with knowledge about your health plan before you need it. So if an emergency does come up, you’ll know what to do:

Decide if you really need the emergency room.

Up to 25% of visits made to the ER are not actually emergencies—they are cases of allergies, coughs, or sprains and strains, which could have been treated in the doctor’s office. Yet when treated in the emergency department, the same care can cost three to four times more. There is also no guarantee you’ll get faster or better service in the ER. Depending on how busy they are, and how urgent your condition is, the average ER wait time can be up to four hours.

Call your plan’s nurse advice line.

Most plans offer this service for free, 24 hours a day. Not sure or want a second opinion? Call back. The benefit is yours, and you’ve paid for it.

Try an urgent care clinic.

 If your condition is not life threatening but also can’t wait for your regular doctor, this might be a good option. While most clinics are not open 24 hours, the costs will be a fourth or a fifth of what an ER would charge. Also be aware that health plans have varying rules on how they cover urgent care visits, so find out before you go.


If you do need to go to the emergency room:

Avoid the ambulance.

Unless the situation is life-threatening, or a person has a neck or spine injury, you may get care just as quickly in your own car. Ambulance fees can be high, and some plans will not cover them if the situation was not actually an emergency. What defines as an emergency can be tricky. According to federal regulations, an emergency is what a “prudent layperson” would determine to be a situation requiring emergency attention. But insurance companies don’t always have the same opinion as Joe on the street, and may refuse to pay a claim. This kind of denial can be appealed, but can be difficult to win. So if the urgency of the situation is unclear, but driving on your own is definitely safe, avoid the ambulance altogether.

Learn your authorization rules.

Some plans require you to notify them before you go to the ER. Others may require that you obtain authorization from your primary care provider first. Under the health reform bill, newer plans can no longer require prior authorization, but plans that were created before the bill was passed in March 2012 (grandfathered plans) are exempt from this rule.

Question your bill.

Start by asking the hospital for an itemized bill. Go over each of the expenses to see if they look right—for example multiple charges for the same thing, services that never happened, or incorrect diagnoses. Since ERs can be chaotic places, with multiple physicians handling one patient, it is not uncommon for a diagnosis to be changed or recorded incorrectly, or for a test to be ordered but never completed. Be aggressive in asking the hospital about charges that don’t make sense or appealing to the health plan if they refuse to cover certain services.

Beware of balance billing.

Most plans are now required by the health reform bill to cover emergency care at the same cost shares for you, whether the hospital was in-network or out-of-network (grandfathered plans are exempt). But in situations where a plan does not have a contract with individual physicians staffing the ER, the plan might reimburse physicians at lower rates than the doctors normally charge. So the physicians then turn around and bill their patients the difference—a practice known as balance billing. Each state has different laws around balance billing when it comes to in-network versus out-of-network providers and HMOs versus PPOs. Find out what the laws are in your state to make sure you are not being improperly billed.

Remember, Simplee does not give medical advice – only financial. If you are unsure about the urgency of your medical situation, always be sure to seek the care you need.