• Ronnie Shalev, MD

Part 2 Series: Billing questions you should ask before having a procedure

Last week I discussed the importance of asking your doctor questions about the medical procedure that you are planning on undergoing. The medical perspective is definitely important, but there is another aspect of your care that you should consider. THE BILL.

Just because your doctor thinks you need to have a surgery doesn’t mean your insurance company will pay for it.

These are the sort of questions you should ask in order to avoid getting stuck with an unexpected medical bill.

Is my specialist in-network?

Hopefully you confirmed this before your new patient consultation with the specialist. However, if you didn’t, I recommend you definitely confirm it before moving forward with any procedure. You can confirm that your specialist is in-network by calling your health insurance carrier customer service line or logging onto your insurance profile and looking for your specialist’s name in the in-network provider list. If they are not there, chances are they are out-of-network.

If you ask the physician staff if your specialist is in-network, many times they answer with “we accept your insurance”. That does NOT mean the specialist is in-network. It just means they will submit the claim to the insurance company on your behalf.

What facility is the specialist affiliated with and is that facility in-network?

The largest portion of your medical bill comes from the facility fee. The physician office staff will have a list of facilities where the procedures are done. It is very important to verify that the facility is in-network. Verifying in-network status can be done online or by calling your insurance carrier.

Which anesthesiology group performs the anesthesia services for the surgeon and are they in-network?

It is not uncommon to go to an in-network surgeon, an in-network facility and still get a surprise medical bill. This commonly happens when the anesthesiologist is out-of network. Even though congress is currently working on new legislation that protects consumers from surprise medical bills, I would still advise to cover all of your bases. Start by finding out from the surgeon who they use for their anesthesia services and by confirming they are in-network. Again use the same process as I described above, either by logging into your health insurance profile or by calling your insurance carrier. If the anesthesiology group is out-of-network, it doesn’t mean you have to cancel your procedure. I would speak to a health insurance representative and request that they honor in-network rates for the anesthesiologist. They oftentimes will do this, especially since you don't have much of a choice when it comes to selecting your anesthesiologist.

Will my insurance cover this procedure?

Before moving forward with surgery, everyone wants to know if insurance will cover it. When speaking to the physician office staff regarding the procedure, always get the name of the intended procedure and the CPT code(s) associated with it. Once you have the CPT code, you can verify your benefits by calling your health insurance customer service line and asking if that specific procedure is a covered benefit. The other significant information to find out is if exclusions for the procedure exist. It is essential to know these exceptions ahead of time so that the medical claim won’t be denied, and you won’t get an unexpected billed.

What is the contracted rate for the procedure?

The contracted rate is the agreed upon or negotiated rate between the insurance company and the healthcare provider (ie, physician and facility) for a specific procedure. For example, the facility might bill $14,000 as their facility fee for a tonsillectomy, however if the contracted rate is $4,000, then the patient ultimately gets a $10,000 “discount” by having health insurance. Insurance companies negotiate with each physician and each facility separately and keep the contracted rates secret. Due to the lack of transparency, different physicians will have different negotiated rates for the exact same procedure. Despite this secrecy, contracted rates for a specific provider can be obtained by asking their billing staff “what is the contracted rate?”. Knowing this information will help give you a ballpark figure as to how much your procedure might cost. Remember to do this for both the specialist performing the procedure and the facility you plan on using.

What is my deductible, coinsurance, and out-of-pocket max? How much have I met already?

Your deductible is a specified amount of money that you are required to pay before the insurance company will pay the claim. If you have a $10,000 deductible and you haven’t met any of it for the year, then you will need to pay $10,000 of medical bills before your insurance kicks in.

Coinsurance is referred to as a portion of the claim you are responsible for after your deductible has been met. Oftentimes these are seen on your benefits page as a percentage: 70%, 80%, 90%, 100%. Your insurance company shares the medical claim with you and pays a portion of it.

These terms can get confusing and sometimes looking at a concrete example helps clarify things.

Medical Bill Analysis Example

Deductible $10,000 Coinsurance 80% Out-of-pocket max of $20,0000

Total surgery cost is $25,000 (contracted rate)

Patient Responsibility: $13,000 of the surgery

( $10,000 deductible and $3,000 coinsurance)

Your health insurance will cover $12,000 of the bill.

Since $13,000 is a significant amount of money, it is helpful to know your financial burden might be ahead of a procedure.

The only way to know is by asking the right people the right questions.

Don't worry, MediBookr can help. By logging into your app, you will automatically know how much of your deductible has been met. MediBookr can also provide you information regarding in-network facilities and physicians. Our advocacy team can also shed light on pricing information, strategies for healthcare savings, medical bill review, and more! Go to www.medibookr.com

-Dr. Ronnie Shalev is a board-certified emergency medicine physician and is the Chief Medical Officer for Medibookr.

#surprisemedicalbills #healthsavings #medibookr