medical bills

Posts Tagged: medical bills


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.


What’s the Difference Between a Deductible and Out-of-Pocket Max?

These are two numbers tell you something about how much you could end up spending out of pocket during the year. But what’s the difference?

Your deductible is how much you must pay out of your own pocket before your health plan starts to pay any benefits. Let’s say your deductible is $2000 and your out-of-pocket max is $5000.  At the start of the year, you should plan on spending at least $2000 on your own medical costs. Of course if you don’t get any health care, or you only get preventive care, you won’t have to pay anything.

Your annual out-of-pocket max (OOP max) is a limit on how much you’ll have to pay towards any health care during the year. In this example, you can relax knowing that you won’t be responsible for paying more than $5,000 towards your medical care, no matter how much care you actually get. The OOP max includes co-pays and co-insurance but not premiums. And sometimes, but not always, it includes the deductible.

Think of your OOP max as a protection (your friend!) and your deductible as a liability (not so much your friend).

Let’s take a deeper look at how the deductible and OOP max are related by pretending you suddenly had some major medical services.

If your deductible does count towards your OOP max, good for you! This means you’ll “get credit” for everything you pay from the beginning of the year. After meeting your deductible, you’d only have $3,000 more to pay before everything is covered. Making the actual amount you pay throughout the year $5,000 .

Now, say your deductible didn’t count towards your OOP. After you paid your $2,000 portion, you would still be responsible for an additional $5,000. That makes a total of $8,000 you’d actually owe in the end.

So while it’s important to know how much your deductible and OOP max are, you also need to know how they relate to one another. It could mean a difference of thousands of dollars in your pocket!


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.


Saving Money with the FSA Grace Period

Did you miss out on spending down your FSA last year?

Hold on, all might not be lost. FSAs and HRAs are “Use it or lose it” accounts, meaning if you do not spend the funds by the end of your plan year, the money disappears.

But did you know that some employers have a grace period for FSA and HRA spending? Federal tax regulations allow them to extend the time for incurring expenses by 2 and ½ months into the new year. The extension is optional (not all employers have to offer it), but if you do have the opportunity, it’s a great way to make sure you don’t lose any of the money you’ve already set aside for medical expenses.

How do I know if I have a grace period?
Talk to your HR Department or benefits administrator. Remember, the grace period must be a benefit they have established in advance–it’s not a last minute change they can just throw in!

What if I don’t have any funds left in last year’s FSA or HRA?
If you’ve already spent down your 2012 FSA or HRA, the grace period doesn’t affect you. You’ll just continue spending your 2013 funds as usual.

If I have expenses for services I got in 2013 during the grace period, how will the money be deducted?
Employers will apply the expenses to your 2012 balance first, and then your 2013 balance (assuming you also elected an FSA or HRA for the current year).

What if I have an HSA?
The grace period doesn’t apply to HSAs because money in these accounts always rolls over year to year, so there’s no deadline to spend it.


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.


Simplee’s Automatic Error Detection Saves Users Thousands of Dollars

Have you had a chance to check out Simplee’s error detection feature yet?

We’ve been hearing from many users about how they’ve saved money or solved billing problems.

First, there was the user who told us he fixed a billing problem in ten minutes, after fighting his insurance company about it for the last four months.

Another user tweeted that he found an error that saved him $1,000.

And then, we interviewed another user who saved over $1,000 on several medical bills just by checking for errors. He said this didn’t even count another several thousand he saved by repeated calling out a separate error: His insurance company denying every claim because it believed he and his family had a second insurance plan that should be paying.

Using Simplee has made it easy for him to spot this error, plus additional ones such as duplicate claims or the incorrect insurance carrier being billed. He then uses Simplee’s notes feature to track the status of claims he’s disputing, so he knows not to pay them yet.

So far, he’s found that over 70% of the claims for himself, his wife, and two kids, contained some kind of problem that needed to be addressed before he paid the final bill.

To review your own account, log in to Simplee and look for our red, orange, and green flags next to a claim. These flags will tell you when we think we’ve spotted a problematic claim or a tip for saving money.

Do you have a success story about using Simplee? Let us know! Your tips could help other members save.


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!


Simplee Now Automatically Screens Your Claims for Billing Errors

Are you ready for an exciting new feature?

We know how painful it is to read through medical bills to make sure you were charged the right amount for the right services. And how even more painful it can be to not read through them and just pay what’s on the bottom line (hoping that you’re not getting screwed).

We’ve been thinking about ways to make it easier to understand your bills—and we came up with a feature that automatically reviews your EoBs (Explanation of Benefits) for some of the most common billing errors, reasons insurance didn’t cover a claim fully, and even strategies for how to save money in the future.

Now, when you get an email from Simplee about a new claim, it will include color-coded flags next to claims where we have identified a potential problem. Click on the claim, and we’ll explain the problem and what you should do next.

We’ve seen an average savings of about $91 on claims that the feature has flagged. Although one user who spotted a billing error through Simplee saved almost $1,000. Our hope is that this new feature will encourage everyone to start looking more critically at their claims and benefits and find ways to put more money back in their pockets.

Studies have found anywhere from 40%-80% of medical bills containing an error, so it’s worth taking a second look, right?

Some of the issues that Simplee will scan for include out-of-network claims, benefit limitations, claims for services that were previously covered, prescription drug costs, and a lot more. Learn more.

What billing errors have you noticed in your EoBs? Let us know at so we can start spotting them for you.

Here’s what you’ll see in your email. Keep your eyes out for it!


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.


Medical Bills you Shouldn’t Pay: The Story of Balance Billing

Think back to that big hospital bill you got when you thought the stay would be covered—even when you made sure the medical center was in your network. Or the outpatient surgery, where there was a huge fee, even though the surgeon said he takes your insurance.

You might have been balanced billed.

In two sentences, balance billing happens when your insurance company and your doctor don’t have an agreement on how much a service should cost. And when the doctor doesn’t think he or she has been paid fairly, you get billed for the difference.

But what’s important is that often times, you are not responsible for the bill. In many states, balance billing in certain situations is against the law.

What is Balance Billing?

Balance billing can occur when you visit a non-contracted (or out-of-network) provider. That provider has no agreement with your insurance company as far as how much he or she should be paid to treat you (most likely, they couldn’t agree on what should be paid, that’s precisely why there’s no contract). That’s why balance billing is most common with HMOs (and sometimes PPOs).

Here’s what happens, in a nutshell:

1) You get care from the provider, and he sends a claim to your insurance plan.

2) The insurance plan doesn’t pay the entire amount (why would they? They’ve made no agreements to).

3) The provider is unhappy. He didn’t get fully paid for his services, after all.

4) The provider bills you for the difference.

Of course, it’s more complicated than this. Knowing whether or not your providers were in-network is not always obvious. And separating balance billing from deductibles and co-insurance (which are legitimate charges) can be confusing.

Remember that providers could include many types of people or facilities: Every doctor that sees you in the ER, the imaging center where you got an MRI, the ambulance company, or the hospital. For example, many balance billing cases occur when an anesthesiologist is non-contracted, even though the surgeon and the hospital are in your network. You hardly get to see the anesthesiologist, let alone ask ahead of time whether he or she works with your plan. The same thing happens in the ER. Most people aren’t about to stop to ask about insurance in the middle of an emergency.


What If You Think You Have a Balance Bill?

1)   Request an itemized bill if the services are not already broken out in detail. There should be separate line items for each provider.

2)   Compare the charges to your network benefits. Have you met your deductible? What are the co-pays or coinsurance? Determine whether the charges exceed your usual cost-sharing.

3)   Call your health plan and ask whether every provider involved was a network provider.

4)   Find out what the rules on balance billing are where you live—every state is different. Contact your state’s Insurance Department or go here for a quick check.

5)   If you believe you’ve been sent a balance bill when it was not allowed, contact your provider. If you can’t get the bill dropped, think about getting help from your state Insurance Department or a billing advocate.

Never ignore a bill—that could end up affecting your credit—but don’t be shy to question the amount that you owe. To learn more about why out-of-network care can cost so much, see Going Out of Network? Read This First.