By: Robert J. Nahoum
THE PROBLEM
You were in an accident, became sick or perhaps contracted the coronavirus. You seek appropriate medical care and are thankful to have recovered. Nothing more to worry about because you are fully insured through an employer-based health insurance plan- right?
Despite being fully insured, you continue to get medial bills. The bills make no sense whatsoever and you can’t get straight answers from your insurance carrier or the healthcare provider because each blames the other. Why are you getting medical bills???
THE RULES
There are only three reasons why anyone with health insurance should receive medical bills:
- Deductibles,
- Co-Payments,
- Co-Insurance
Deductibles
Deductibles are the amount of money you must pay before your insurance plan kicks in. You can think of it as paywall you must breakthrough before your insurance pays its share. Better and more expensive health plans have lower deductibles or sometimes no deductibles at all.
Commonly, many health plans have higher deductibles for “out-of-network†healthcare providers. The best way to avoid these higher, out-of-network deductibles is to make sure ahead of time that the healthcare provider you are seeing is in-network. If you have any doubt whether a particular provider is in-network or out of network, call and confirm ahead of time with both the prover and your insurance carrier. Makes sure everyone is on the same page beforehand.
But what happens when you don’t have the opportunity to choose the provider? For example, if you are in a car accident and taken to the hospital, just because the hospital takes your insurance does not necessarily mean that every provider you see while hospitalized is in-network. Each provider you see is an individual provider. This includes doctors, anesthesiologists, nurse practitioners and more.
This practice results in what is called “surprise billing†where after you are discharged you receive a surprise by a bill from an out-of-network provider for the full cost of their services. Many states, including New York where I practice, surprise billing is outlawed. Nevertheless, whether from carelessness or honest mistake, surprise billing does happen. Undoing a surprise bill can take a tremendous amount of advocacy from the patient.
Co-Payments
Co-pays are often confused with deductibles, but they are not the same thing. A copay is a fixed amount you pay to the healthcare provider for each covered medical service. The remaining balance after the copay is paid by the insurance company.
The amount of the copay depends on each individual policy and can vary depending on the type of medical service provided. For example, some policies have different co-pays for hospitals than they do for labs or regular doctor visits.
Insurance companies pay far less to healthcare providers than the uninsured. The insurance companies have pre-negotiated schedules of rates. So, what happens to the difference between the total cost of the service and what the insurance company pays? Billing a patient for the difference is called “balanced billing†and is outlawed in most states including New York. As with surprise billing, balance billing, whether from carelessness or mistake, does still happen and requires advocacy from the patient to undo.
Co-Insurance
Some lower-end insurance policies require the patient to kick in a percentage of the cost for all medical services provided. This is called co-insurance. The applicability and amount of coinsurance can vary according to a variety of factors including the service being provided and the medical facility. Many insurance policies have an out-of-pocket cap comprised of copays and coinsurance. Once the patient reaches the cap, he or she no longer has to make the coinsurance contribution.
Medical billing is complex and fraught with mistakes. For this reason, coinsurance errors are often the cause for inaccurate medical bills.
WHAT YOU SHOULD DO
Medical bills can be overwhelming. Patients can understandably feel helpless especially when the medical bills make no sense. By some estimates 80% of medical bills contain errors which may violate the laws prohibiting surprise billing and balance billing.
If you need help settling or defending a debt collection lawsuit, stopping harassing debt collectors or suing a debt collector, contact us today to see what we can do for you. With office located in the Brooklyn and the Hudson Valley, the Law Offices of Robert J. Nahoum defends consumers in debt collection cases throughout the Tristate area including New Jersey.
The Law Offices of Robert J. Nahoum, P.C
(845) 232-0202