Posts Tagged: out-of-network

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.


How to Start a New Health Plan Off on the Right Foot

Welcome to a new year, with new health benefits. You just chose a new health plan and now it’s in full effect. But most people don’t have a full understanding of how their benefits work. This means that many of them end up losing money in their spending accounts, paying more for care, or getting claims denied.

Follow these tips to make sure you start off 2013 right.

Plan for your Deductible
Guess what–deductibles have gone through the roof over the years, so that often means more cash out of your pocket. If you are one of the 65% of people who have a high deductible health plan, it’s especially important for you to plan your spending. High deductible health plans (HDHPs) come paired with Health Savings Accounts (HSAs), or accounts where you can save money just for medical expenses free from taxes. To be best prepared, you should plan to save at least the amount of your deductible in your HSA as soon as possible.

Network It
Most health plans have some restrictions on what providers you can see or they cover much more on visits to in-network providers. Find out the type of plan you have and whether you have a provider network. HMO plans are the most restrictive–don’t even think about going to a non-network provider unless you want to pay the full cost. PPOs have some more flexibility, but services in-network will be less expensive. POS plans give you more freedom, but often involve more paperwork for out-of-network visits. And finally, FFS plans allow you go to any provider you want, but few companies offer this option anymore.

Get Spent
Did you sign up for an FSA or HRA? Don’t forget about the money in your account. These funds disappear if you do not spend it by the end of the year. Do some planning now by finding what eligible expenses you expect this year so that when they come up, you’ll know to pay with your FSA or HRA, insteading of other funds. If you have an HSA, the same “Use it or lose it” rule does not apply. Your savings will roll into the next year.

Practice Prevention
All health plans must cover a list of dozens of preventive care services, all free of cost. Get your money’s worth by checking out the list and asking your physician what they recommend. Even if you have a high deductible plan and you have not met your deductible, you can still get these services completely covered, as long as you don’t have a pre-existing condition that already required one of these tests or screenings. Learn more about preventive care here.

Have a Non-Emergency Plan

What do you do on the weekend or in the middle of the night when you’re not sure if a medical condition is serious enough for the ER or can wait for a doctor’s appointment?  Most health plans have a variety of options for these uncertain situations such as nurse advice lines or extended-hours urgent care. Know your options so that if you’re caught in the situation, you can choose to avoid an expensive ER visit. Of course, always go to the ER if you are having a life-threatening emergency.


Before 2013: Squeeze Extra Dollars Out of Your Health Benefits

Before the new year rolls around, putting some attention towards your health benefits can save you a lot of money. Quick! You have limited time to make the most out of your health plan for 2012, and then to get ready for 2013.

Spend down your FSA or HRA 

If you have a Flexible Spending Account or Health Reimbursement Account, check on the date it rolls over (for most of them, it’s January). You’ll lose the funds if you don’t spend them in time. Some employers offer a grace period until March 15th, but after that date, the money disappears. See what expenses can be counted.

Don’t confuse your HSA. These funds stay with you year after year!

Take advantage of your deductible

Most plan deductibles also roll over at the end of the year. If you have already met your deductible, think about whether there are any other services or procedures you need to do soon. Scheduling them before the year ends might save you from having to pay completely out of pocket in the new year.

Fund your HSA

If you have an HSA, you already know that the money that goes into it is free from taxes. Did you also know that you can keep depositing up until April 15th and your contributions will count towards your 2012 income? That means you can add more funds if you didn’t deposit enough this year or aim for the maximum contribution to get the most tax savings.

Review next year’s plan

It’s time to look at what’s new for your health plan (or all the important details if you switched plans!). The top benefits to focus on? The deductibles (individual and family, as well as in-network and out-of-network), any changes to the drug formulary, and any changes to the provider networks. These last two rule changes often surprise consumers who think their plan will be the same as it was last year.


Why Understanding Your Health Plan Just Got a Bit Easier

Wouldn’t it be great if overnight, understanding health insurance magically became easier?

That was the aim September 23, 2012, but whether it actually happened is still in question.

On the 23rd, a new benefit from Health Reform kicked in, aimed at making it easier for consumers to understand insurance and compare plans.

It’s called the Uniform Summary of Benefits and Coverage (SBC). Right now, health plans already send you long, complicated SBCs. But the problem is, every one is different (ever tried to compare two of these?).

But now, every plan will be required to present their information in a standardized way, using the same definitions, so you can compare apples to apples.

Think of nutrition labeling—we can see instantly exactly how much more sodium is in one bag of chips versus another. That’s the goal behind the Uniform SBCs. And the “labels” actually don’t look that different from what’s on your food…

Even better, the new document also include “coverage examples,” or a theoretical breakdown of costs for some common medical conditions. See example SBCs here.

It’s a step forward, but here at Simplee, we know it’s not enough to make shopping for health insurance as easy as shopping for sweet potato chips. For example, it’s still difficult to compare 70% and 80% co-insurance when you don’t know the full cost of a service.

Basically, the new SBC will make is easier for consumers to choose between health plans, but after that, it’s still a challenge to understand claims and bills once you start using the plan.

Everyone with a private health plan will see this benefit. Look for it when you receive your plan documents each year or on your health plan’s website.



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.


Going Out-of-Network? Read this First.

If you have an HMO or PPO, you know that going to your plan’s network providers will save you money. But for those cases where you really want (or need) to see a specific doctor, and they’re not in the network, it might be worth the extra cost. After all, if co-insurance is 80% in-network and 50% out-of-network, how big will the difference really be?

The answer is not so straightforward. Or in other words, it could cost a lot more than expected, even if you obtain prior approval from your plan.  Here’s a behind-the-scenes of going out-of-network.

So why the network in the first place?

In-network providers have made a deal with your health plan to accept a certain rate of payment for each service they provide. But there’s no such deal with out-of-network doctors, so most of the time, they are going to bill the plan more than that agreed-upon rate. It’s a way for health plans to control their costs and for providers to ensure they get some guaranteed patient flow.

Why you might pay more than expected

Health plans have a strange way of calculating how much they will pay an out-of-network provider, and now, many plans have begun to change that method in order to control their costs.

Let’s say your surgery cost $10,000 and your PPO plan says it covers 50% out-of-network. You would think they would pay $5,000, right? But instead of looking at what the procedure really cost, health plans typically use the UCR or “Usual Customary Rate,” a kind of industry average, and calculates 50% of this. So if the hospital you went to is not wildly expensive, the UCR would be just about right.

Many plans are now switching from UCRs to Medicare rates—which tend to be a lot lower. So if Medicare’s rate for the surgery is $4,000, the plan will pay $2,000.  You can imagine what the hospital might do after providing a $10,000 surgery and then getting paid $2,000.  Yes, you might expect a bill for the remaining $8,000. These numbers are a bit simplistic, because there is usually a multiplier to bring the Medicare amount up since it’s normally pretty low, but you get the idea.

This practice is known as balance billing. It’s illegal for in-network claims and emergency care in most states, and for people with Medicare, but otherwise allowed if you went out-of-network. So what to do? It’s best to know before you go: Read your plan’s policy to see how it calculates these reimbursement rates and find out whether balance billing is allowed in your state. If you do end up with a balance bill, try negotiating with the provider. Many will lower the cost or figure out a payment plan with you.

Beware even if you have prior approval

If you still plan to go out-of-network, you may be able to get prior approval from your plan if for example, the service can not be adequately provided in-network. If you do this, make sure you know exactly who and what is covered: while a specific surgeon may be approved, other physicians involved with the procedure, such as an anesthesiologist, may still be considered out-of-network, even if they work at a hospital that is in-network.

The same goes for follow-up care, even if it is with the same physician. The bottom line? Don’t assume everything is approved just because one thing is.

Of course, the best bet for keeping your costs down is staying in-network. But if that’s not possible, first try for prior approval and make sure you know exactly what is approved. If you can’t get approval, make sure you understand how out-of-network rates are calculated before making your appointment. After that, watch your bills and Explanation of Benefits for multiple charges for the same thing.


Simplee Helps Craig L. Save Almost $1,000

I wish I had some video of the silly dancing and cheering we were doing around the office when we read this great letter from user Craig L. about how Simplee saved him almost a thousand smackeroos!

Hi there.  I quickly wanted to share my Simplee success story.

We have a son with a disability and he receives many different therapies.  I get statements from our insurance provider, but cannot often make heads or tails of what is being reimbursed, at what rate, and why.  With the help of Simplee, I was able to catch a $968 error.

It turns out that for a particular therapy, we were being reimbursed at the in-network 90% rate up through the end of last year.  At the start of this year, for some reason, for this same therapy, we were being reimbursed at the out-of-network rate of 70%.  Given the complexity of statements, I didn’t catch this on my own.  Armed with the simplicity of Simplee, I was easily able to see the discrepancy.

I called the insurance provider and pointed out the error.  They acknowledged the issue and sent us a check for $968.

Without Simplee, I would not have caught this on my own.

So, thank you very much for saving me a ton of money!!

Thanks, Craig!  We are so thrilled we could help you and your family.  Hearing stories like this makes all the hard work completely worth it.

If you’re not using Simplee yet, why the heck not?  Sign up and see what you can save.