Last summer my wife had shoulder surgery and eight months later the bills are still coming in. Yes, we have health insurance, but as everyone who’s ever had a large medical procedure knows, you get bills from people you didn’t even know were in the operating room.
I had some idea how to handle this situation already, but this experience has taught me a few things about how to deal with medical claims, and that’s what I want to share.
Here are a few cosmic realities about healthcare and health insurance that we all need to be aware of going into any medical procedure:
- health insurance plans are riddled with co-pays and co-insurance provisions—you will always have to pay something
- health insurance plans contain exclusions and other gotcha provisions
- medical providers are not always good at coordinating with insurance companies
- health insurance companies and large healthcare providers are both bureaucracies
- we are ultimately responsible for any and all unpaid medical expenses
The best ways to handle all of these obstacles is to get involved (early) and then to be relentless. And I mean relentless!
What to do before your medical procedure
We’ve all heard the saying “an ounce of prevention is worth a pound of cure”—no where is this more true than before a large medical procedure. This is where the financial disasters start and once they do they’re almost impossible to undo. Take charge early and be bold.
Set up a folder and a conversation/action log. It usually takes months to settle a single claim so you need to dig in and organize yourself for the long haul. Set up a dedicated file folder where you’ll keep any communications related to your procedure. This should include medical bills, insurance statements, email copies, and phone conversations.
Speaking a phone conversations, set up a phone log where you’ll record the date, time and purpose of a call—outgoing or incoming—along with the name, position and phone number of the person you spoke with. Make sure there’s room to describe what transpired with the call and be as detailed as you can. All calls related to your claim should be included in the log.
Verify your coverage. Never make the assumption that a procedure or surgery is covered, and don’t leave it to the administrative staff at the provider to verify. It’s your health insurance and your responsibility to investigate.
At a minimum, call your insurance company to verify that your procedure will be covered. Ask for a mail or email confirmation, and if they won’t do that (they often won’t), make a second call in reference to the same issue but to a different person at the insurance company. Include details in your phone log.
Pre-certifications. You can’t afford to drop the ball on this one! My wife needed several pre-certs, and none were provided to the insurance company by the provider—every claim was held up as a result! We were able to get all of the pre-certs after the fact and had one in our file already so all claims were ultimately paid. Pre-certs are the key to the entire healthcare provider/health insurance company relationship, so my advice is to get a copy of the pre-cert for any procedure you have before having the procedure done. This step is SUPER important.
What to do after your medical procedure
Even if you did all the right things prior to surgery there will still be bills coming in. What do you do then?
Stay on top of the medical bills. There’s often a tendency to ignore medical bills under the assumption that the insurance company will take care of it. Don’t make that assumption—ever. Review all bills when they come in to see what’s being paid and what isn’t. If a bill sits out more than a few weeks there’s usually a problem (like no pre-cert obtained). You need to get involved as soon as you see this happening. Medical bills don’t get better with age—the longer they sit outstanding the fewer options you have.
Be the go-between for the provider and your insurance company. Usually providers and insurers coordinate as part of a network group, but that’s never as cozy as it sounds. You must get involved, especially when the process seems to be breaking down, and it will at some point. Yes, the provider should furnish everything to the insurance company, and yes, the insurance company should follow up if they don’t, but that’s not always what happens. When it comes to anything medical you are your own best advocate. Get involved to what ever degree is necessary.
Dealing with large balances insurance wouldn’t pay. This can happen even if you have insurance. A $2,000 deductible and a 20% coinsurance provision (up to just the first $10,000) can leave you with a $4,000 bill after insurance had paid their portion. Ignoring this can lead to collections calls and problems with your credit report so it’s best to make an effort to work something out.
If you don’t have the money to pay immediately call the provider and work out a payment arrangement. Most providers will work with you on this, and if they won’t, offer to pay a large chunk up front as a “down payment”. If the bill puts you in a financial hardship let the provider know—they’ll sometimes forgive a portion of the bill.
Never get nasty with anyone, but rather try to enlist their sympathy and you’ll get a better arrangement. There are no set rules here so you’ll need to bring out your inner negotiator and do your best. If you don’t feel able to do this, get a trusted friend to do it for you.
As much as we’d like to believe that we shouldn’t have to worry about any of this (because we have insurance) the reality is quite different. Any medical procedure sets off a chain reaction of financial issues that are best dealt with quickly. When you have a plan and you know what needs to be done to bring it all to an end, you’ll save time, aggravation—and money.
Have you had to deal with the financial fallout of an expensive medical procedure? What other tips would you recommend to someone going through it now?
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