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Navigating the Maze of Medical Bills

by Kurt Ullman, RN

Let’s say you see your doctor for a check-up. That’s simple enough. You are examined and sent on for blood work or an x-ray. So far, so good. But when the paperwork starts rolling in, the fun begins — you have to sort out what, and whom, you really owe.

Medical bills can be among the more frustrating features of modern life. But you don’t have to be a certified accountant to figure them out and make sure that you are being charged fairly and accurately. The following tips can help you find your way through the maze of medical bills.

Before your appointment

Most of the time, the route to saving money and avoiding problems with medical bills begins before you even see your health-care provider. To keep costs down, most insurance companies have a list of preferred doctors, laboratories, pharmacies, and other providers. Generally, if you go to these “in-network” providers, you save money by paying lower copayments and deductibles.

You also need to keep in mind that just because the doctor you see for your arthritis is in your insurance network, it does not mean that the other providers that doctor sends you to are as well. As a courtesy, some offices will find out which needed providers are in-network for their patients. However, some practices do not check, so you should call your insurer’s customer service telephone number or go to its Web site to determine the status of other providers. It is ultimately your responsibility to make sure the providers you see are in your insurance network.

Whether you are sent to another office for tests may depend on your insurance plan. “What needs to be done outside the office is related to the insurance company’s contract with a practice,” says Annabell Rodriguez, office manager for Arthritis Associates in San Antonio, Texas. “Some [insurance companies] let us do all of the x-ray or laboratory work in-house. For others, our agreement says we have to send patients elsewhere.”

Still, you will want to make absolutely sure that everything is covered. “Always check with your insurance company about anything that is done outside the doctor’s office,” says Candice Butcher, chief executive officer of Medical Billing Advocates of America in Salem, Virginia. That’s true even if the other provider is only a few doors down. “The laboratory or other service being in the same office building as your physician is not a guarantee that they are in your network,” says Ms. Butcher.

Preauthorization. Another potentially costly landmine is the need for preauthorization. Certain kinds of treatments and procedures often require authorization from the insurance company before they are covered. If you don’t get this approval, the company may not have to pay for the treatment, depending on your specific insurance contract and state law. Preauthorization is often required for procedures such as joint replacement and other nonemergency surgeries. People with rheumatoid arthritis (RA) and other rheumatic conditions may need to get approval from their insurance company before their insurance will cover expensive biologic treatments such as adalimumab (Humira) and etanercept (Enbrel), which are not available in generic formulations.

In addition, insurance companies may cover only low-cost generic versions of brand-name drugs. “The insurance company often has a generic or cheaper form of a medication that they will pay for,” says Rudy Molina, MD, chair of the Insurance Subcommittee of the American College of Rheumatology and a physician in private practice with Arthritis Associates. “If I want to make sure my patient gets a certain [brand-name] medication, I need to justify it to the insurance company. Even then, preauthorization is not a guarantee that it will be covered indefinitely.”

Most of the time, the doctor’s office or the hospital will do the paperwork and make phone calls necessary to get preauthorization. However, both Dr. Molina and Ms. Rodriguez suggested contacting both the provider and the insurance company to make sure there have been no communication problems. You should also get a letter from your insurance company confirming its decision.

The avalanche of paper

All of the preliminaries are now completed. You have seen only in-network health-care providers, and all seems right with the world. But soon begins the paperwork avalanche. You will probably receive three types of paperwork in connection with a medical treatment or procedure:

• A summary bill from the provider
• An explanation of benefits (EOB) from your insurance company
• A final bill from the provider

The final bill is pretty straightforward, but you may find the summary bill and explanation of benefits difficult to decipher.

The summary bill. “Normally the first thing you see is a summary bill,” says Ms. Butcher. “This lists in general terms what was done during the visit.” The summary bill is usually just to let you know that a claim has been filed with your insurance company. Most of the time it does not indicate how much money you actually owe.

Last Reviewed on January 11, 2012

Kurt Ullman has been a medical writer for more than 25 years. He is based in Indiana.

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