To determine how you can reduce your medical expenses, MyLupusTeam sat down with Susan Null of Systemedic, a medical bill advocacy firm in New York. Null shared her top tips for finding ways to cut your health care costs.
When it comes to your insurance policy, it’s important to understand the details of your out-of-pocket expenses, copayments, coverage guidelines, and more. “People make an awful lot of assumptions about what their policy covers, and some people just think, ‘I have insurance, so therefore I'm OK,’” Null said. “They forget the fact that they have to ask questions — this is particularly true for people with chronic conditions, who are going to be in the health care system on an ongoing basis.”
Critical questions to ask about your policy include:
“People may forget to check to see if someone's in-network, or they'll immediately get a test done wherever their doctor tells them to go without checking in advance to see if it was the least expensive option,” Null said.
When it comes to medications, don’t forget to ask your physician if a generic version of a drug will work just as well as the brand-name option. Never assume that the pharmacy benefits on your health plan will be the most cost-effective route. “Do a little bit of legwork to find out other places where there could be coupons, reduced prices, or even programs through a manufacturer that can save you money on drugs,” Null said.
Null recommends searching for websites that may help you find reduced-cost medications, which may be less expensive than using an in-network pharmacy with your prescription insurance benefits. “Depending upon what your disease category is, there may be an option that’s very specific to your condition. So searching online is a great first step,” Null said.
“You might also want to go directly to the drug manufacturer and see what programs they have available that could help pay copays, or pay for medications in general, because — particularly for the newer medications that are much more expensive — there could be programs that would help,” she said.
If you’re assuming your medical bills are being charged, processed, and paid correctly, you could be wrong, Null said. “One of the general statistics out there is that 80 percent of medical bills have an error,” she noted.
Medical claims are touched by a variety of entities along the way, from the physician to the biller, insurance reps, or other third parties. “It really is incumbent upon the patient to make sure that before they pay a bill, they've done their due diligence,” Null said. “Get a detailed, itemized bill so you can see exactly what was charged, and compare that to the services that were actually rendered. Maybe you were supposed to have an EKG, but the doctor decided not to perform it — and yet you got charged for it anyway. Things like that can be easy to catch.”
After you confirm that everything on the bill was actually provided, the next step is to compare the bill to your explanation of benefits (EOB) from your insurance company. “Go over that line by line,” Null said. “If the EOB doesn’t match the bill, you’ve got to dig even further so you can find out why.”
If you don’t confirm that all charges are legitimate and appropriate, you could face one of two outcomes. “The first reaction is often to pay the bill without even thinking about it, and potentially overpay for something that shouldn't have been paid. The second is to ignore it and assume the mistake will be caught by someone else. Then the next thing the patient knows, they get a letter from a collection agency, because the provider assumes you have no intention of paying the bill,” Null said.
In short, having insurance represents just the tip of the iceberg in terms of paying your medical expenses. “If you were going to buy a house or buy a car, you’d check the bill,” Null said. “It’s the same thing with health care.”
You have a right to request detailed bills from your medical providers, and if they don’t automatically send itemized bills to you, then you should ask for them. “If you request that information and your medical office gives you a hard time, ask for a supervisor and work your way up,” Null advised. “Take notes from every conversation you have, ask for names and reference numbers, so if you ever need help in the future, you know who to contact.”
If you find errors on your medical bills or insurance EOBs, it’s important to address them swiftly, Null advises. If you see a service on a bill that you know wasn’t performed, call the provider and ask them to pull the records to confirm that the service wasn’t performed so they can correct it with the insurer and adjust your bill.
If, however, you receive an insurance denial because the insurer says something isn’t covered, that may take a little more sleuthing. “Ask the insurer to show you the policy where it says the service isn’t covered,” Null said. “Perhaps they may say the service is covered, but not for your specific diagnosis. Then you can check with the doctor and make sure they reported an accurate diagnosis for your service.”
If you find that the office billed your service correctly and the insurer was right to deny it, your next option is to talk to the medical provider and let them know that you didn’t realize the service wouldn’t be covered, and you wouldn’t have undergone the service if you’d known. “If insurance won’t cover it, you’re considered a self-pay patient for that service, and it’s possible the doctor may provide you with a discount to lower the amount you owe,” Null said.
You’re in a better position to negotiate your medical expenses before the physician performs a service rather than afterward, so Null recommends confirming coverage before you arrive for any tests, office visits, surgeries, or other visits.
“Before you go to your appointment, ask the provider for the procedure code and the diagnosis code for the service that they’ll be providing,” Null advised. “Once you have that information, call your insurance company and say, ‘Here are the codes for what I plan to have done, as well as the name of the provider. Can you tell me what is covered and what my responsibility will be?’ They’ll look up your policy’s specifics and can tell you what they project you will have to pay out-of-pocket. Of course this is an estimate — nothing is guaranteed until they get that detailed bill from the doctor — but it can give you a good idea of what kind of cost you’re looking at.”
“If you call your insurer for a preapproval and the insurance representative says the service isn’t covered, you can go to the doctor and say, ‘I really do want to have this treatment. I spoke to my insurance company, and it's not going to be covered. Can you work with me on setting a fee I can afford?’ This allows you to negotiate up front, before any services have been performed,” Null said.
Keep in mind that there are situations when negotiating won’t be an option. For instance, if you have a $1,000 deductible and you’re seeing the doctor for a $500 service, you will be responsible for paying that $500, because you haven’t met your deductible yet. So it’s essential that you know your policy provisions and that you self-advocate whenever possible.
Some insurance plans will provide benefits if you see providers that aren’t in their network, but that’s not always the case. “With commercial insurance, there are plans that have out-of-network benefits, so you will potentially get some coverage for a doctor who was out of your network. But Medicare and Medicaid won’t cover out-of-network providers, and this is essential to know,” Null explained.
If you do have out-of-network care, you must understand how those benefits are calculated. When a doctor, hospital, or lab is in-network, there's a contract between the provider and the insurance company for every service they bill and how much they’ll pay for each one.
“Regardless of what they charge, the only thing they can ever ask you to pay is the allowed amount,” Null said. “But when you’re out-of-network, there's no such contract, and that can result in significant bills for people.”
Checking on your coverage and your network status isn’t just important for office visits and diagnostic tests, but also for hospital visits. “If you come in as an emergency, most insurance companies, even if the hospital is out-of-network, will cover you — but they're going to do that algorithm of how they determine what the benefits are going to be. And the hospital then can determine if they are going to balance-bill you,” Null said.
If you’re going into the hospital for an elective procedure such as a colonoscopy, an X-ray, or a mammogram, “you must check whether the facility is in-network ahead of time, because if you're out of network, you're totally self-pay,” Null said. “Price-wise, a hospital would be one of the worst places you could go for something like a colonoscopy, X-ray, or blood work, because hospitals charge the most.”
Find out if your physician could instead refer you to a stand-alone, independent facility; an outpatient surgical center; a freestanding blood lab; or another nonhospital location where the costs will be easier to manage, Null suggests.
Anyone dealing with a chronic condition should pinpoint the locations with the most cost-effective care and write them down, Null recommends. “You'll want to find the pharmacy location — whether it's online, a large chain, or a local mom and pop — where you're going to be able to get that medication in the least expensive way,” Null said. “Find the testing locations that are going to be in-network with your plan so you can keep your expenses down. And then keep an eye out for bills and explanations of benefits. And when they come in, deal with them immediately or as immediately as possible.”
If you can’t address your medical expenses proactively or after the fact because you’re so focused on managing your health, work with someone who can help. “It may be a family member, a friend, an advocate who you might need to bring on — but don't ignore it, because ignoring it is only going to get you into a worse hole eventually,” Null said.
On MyLupusTeam, the social network and online support group for people with lupus and their loved ones, members have discussed the high out-of-pocket costs of dealing with lupus.
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