How can this happen?! Because of a “loophole” in the insurance system, what starts out as a preventive screening may turn into a diagnostic procedure (i.e. if  samples are removed for closer examination or polyps are removed during the colonoscopy), which allows your insurance company to bill you. Or if your doctor orders you to have a colonoscopy because of a medical concern, it no longer falls under the preventive care provision.

How will you know what you owe?

Gather your personal coding information

Obtain the preoperative CPT and diagnosis codes as well as the facility name from your provider.

Call your insurance carrier and verify the benefits and coverage by asking the following questions. ( You will need to give the insurance representative your preoperative CPT and Diagnosis codes.)

1. Is the procedure and diagnosis covered under my policy? Yes        No

2. Will the diagnosis code be processed as preventative, surveillance, or diagnostic and what are my benefits for that service? (Benefits vary based on how the insurance company recognizes the diagnosis).

Diagnostic/Medical Necessary Benefit:
Deductible: _____________   Coinsurance Responsibility: ___________
Facility in Network:         Yes       No

Preventative/Wellness/Routine Colonoscopy Benefits:
Are there age and/or frequency limits for my colonoscopy? (e.g. one every ten years over the age of 50, one every two years for a personal history of polyps beginning at age 45, etc)  No         Yes if so; ______________

Deductible: _____________    Coinsurance Responsibility: _______________

3. If the physician removes a polyp, will this change my out of pocket responsibility? No      Yes

Representative’s Name: _________  Call Reference #: _________ Date: ____

Make sure you understand the confusion around this screening or you too could end up with a surprise bill.

Ambulatory Care – Health care services that do not require a hospital stay, such as those delivered in a doctor’s office, clinic or day surgery center.

Assignment of Benefits – This means signing a document that allows your hospital or doctor to collect your health insurance benefits directly from your health carrier. Otherwise, you pay for treatment and the insurance company reimburses you.

Benefits – The amount of money payable by an insurance company to a claimant under the insurance policy.

Capitation – Represents a set dollar limit that a health maintenance organization (HMO) pays to your primary care physician for providing medical treatment to you and your dependents. The fee is usually paid to the physician on a monthly basis. The physician gets no more or less than this set fee, no matter how much or how little you use his or her services.

Case Management – A technique that insurance companies and HMOs use to ensure that individuals receive appropriate, timely and reasonable health care services.

Claim – A request by an individual (or his or her provider) for the insurance company to pay for services obtained.

Coinsurance – The money that an individual is required to pay for services, after a deductible has been paid. It is often a specified percentage of the charges. For example, the employee pays 20 percent of the charges while the health plan pays 80 percent.

Copayment – An arrangement where an individual pays a specified amount for various health care services and the health plan or insurance company pays the remainder. The individual must usually pay his or her share when services are rendered. The concept is similar to coinsurance, except that copayments are usually a set dollar amount (such as $20 per office visit), rather than a percentage of the charges.

Deductible – A set dollar amount that a person must pay before insurance coverage for medical expenses can begin. They are usually charged on an annual basis.

Denial of claim – Refusal by an insurance company to pay a submitted request for health care services obtained.

Employee Assistance Program (EAP) – Mental health counseling services that are sometimes offered by insurance companies or employers. Typically, individuals or employers do not have to pay directly for EAP services provided.

Exclusions and Limitations – Specific conditions or circumstances for which an insurance policy or plan will not provide coverage (exclusions), or for which coverage is specifically limited (limitations).

Health Maintenance Organization (HMO) – Prepaid, or capitated, health care plans in which individuals pay a small monthly fee to be a member of the HMO, as well as small fees or copayments for specified health care services. Services are provided by physicians and allied health care personnel who are employed by or under contract with the HMO. HMOs are available to both individuals and employer groups.

Indemnity Plans – Also known as “fee-for-service” plans, these existed primarily before the rise of HMOs and PPOs. The individual pays a predetermined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other remaining charges. Fees for services are determined by individual providers, and therefore vary from physician to physician. Indemnity health plans allow individuals to choose their own health care professionals – there are no provider networks from which to choose.

Independent Practice Association (IPA) – A group of independent practicing physicians who band together for the purpose of contracting with HMOs, PPOs and insurance companies for their services.

In-Network –Typically refers to physicians, hospitals or other health care providers who contract with the insurance plan (usually an HMO or PPO) to provide services to its members. Coverage for services received from in-network providers will typically be greater than for services received from out-of-network providers, depending on the plan.

Long-Term Care Insurance – Insurance policies that cover the costs of providing nursing care, home health care services, and custodial care for the aged and infirm.

Managed Care – A system of health care delivery that is characterized by arrangements with selected providers, ongoing quality control and utilization review programs, and financial incentives for members to use providers and procedures covered by the plan.

Maximum Benefit – The maximum dollar amount that an insurance company will pay for claims, either for a specific service or procedure, or during a specified period of time.

Medically Necessary – A term used to describe the supplies and services needed to diagnose and treat a medical condition in accordance with the standards of good medical practice. Many health plans will only pay for treatment deemed medically necessary. For example, most plans will not cover elective cosmetic surgery.

Out-of-Network – Typically refers to physicians, hospitals or other health care providers who do not contract with the insurance plan (usually an HMO or PPO) to provide services to its members. Depending upon the insurance plan, expenses incurred for services provided by out-of-network providers might not be covered, or coverage may be less than for in-network providers.

Out-of-Pocket Maximum – The total amount paid each year by the member for the deductible and coinsurance. After reaching the out-of-pocket maximum, the plan pays 100 percent of the allowable charges for covered services the rest of that calendar year.

Point-of-Service Plan (POS) – A type of HMO that allows the patient to see either in-network or out-of-network providers. However, the patient pays more out of pocket when using an out-of-network provider.

Pre-Admission Certification – Also called “precertification” or “pre-admission review.” Approval granted by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or inpatient facility before admittance. The goal is to ensure that individuals are not exposed to inappropriate health care services, or services that are not medically necessary.

Pre-Existing Condition –Any medical condition that was diagnosed or treated within a specified period immediately before a health insurance policy became effective. These conditions may not be covered for a specified period of time under the new policy.

Preferred Provider Organization (PPO) – A type of managed care plan in which doctors and hospitals agree to provide discounted rates to plan members. Patients are typically reimbursed 80 to 100 percent for treatment received within the network, versus 50 to 70 percent outside the network.

Primary Care Physician (PCP) – A health care professional who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a gatekeeper for an individual’s medical care, referring him or her to specialists and admitting him or her to hospitals when needed.

Reasonable and Customary Charges – The commonly charged or prevailing fees for health services within a geographic area. If charges are higher than what an insurance carrier considers reasonable and customary, the carrier will not pay the full amount and instead will pay what is deemed appropriate for the particular service. The remaining charges then are the responsibility of the patient.

Self-Insured – A health benefits plan in which the employer is responsible for the cost of its employees’ health care. Typically, a third party provides administrative services for the plan to the employer group.

Waiting Period – A period of time in which your health plan does not provide coverage for a particular pre-existing condition.

Waiver – A rider or amendment to a policy that restricts benefits by excluding certain medical conditions from coverage.

1) Use “in-network” providers.

If you have health insurance you should be sure the physicians you see are in your insurance carrier’s network. If you are not sure whether the physician is in-network, call your insurance company to find out prior to your visiting the provider.

2) Ask for a discount

If you do not have insurance, some doctors will give you a cash discount of 10-50% for paying cash up front.

3) Save on medications

Check with your doctor to see if there are generic medications to replace your brand name ones. (See Generic vs. Brand Medications)  Be sure to call around and check the prices for your prescription at warehouse club and discount/chain store pharmacies. By law, warehouse clubs have to let you purchase from their pharmacy even if you are not a member.

4) Appeal to insurance to have services covered

If a procedure is not covered under your health insurance, follow the appeals process shown on your explanation of benefits to see if the insure will cover your care.  It never hurts to try!

5) Read medical bills

Ask for an itemized bill and read it carefully. If the bill is large and confusing, hiring a medical billing consultant, may give you peace of mind that there are no erroneous charges and that your insurance processed the claim correctly.

6) If you can not afford to pay a bill

If you are not able to pay a bill, call the provider and ask to speak with the billing office manager. Explain your situation. Then follow up with a letter, outlining why you cannot pay in full and/or cannot pay at this time. If you do not get a resolution that you can afford, continue calling or writing, and ask to speak to higher-level managerial staff who might be able to discount your fees. Be sure to keep records of whom you spoke to and when you spoke to them.

7) If you are unemployed or do not have health insurance

If you are unemployed, do not have health insurance and truly cannot pay a bill, talk with your physician’s office or hospital about how to get help. They should be able to direct you to your state’s agency or other resources. Be prepared to provide substantial proof that you cannot pay.

Medical debt causes almost 2 million bankruptcies a year. If you do not have health insurance, you do have options to reduce and prevent high medical bills.

Negotiate a cash discount

Cash Discount: Many doctors, clinics, and hospitals will generally offer a 20-30% cash discount off your medical bills if you can pay them off in full.

Negotiate a payment plan: Call your hospital billing department, doctor’s office or medical clinic. They don’t want to send your debt to a collection agency because they then lose money too.

Hire a Medical Bill Advocate: If you are inexperienced or uncomfortable with negotiating, work with a company that can do the negotiation for you. Having someone experienced, who understands the insurance lingo, can help you obtain the largest reduction. Plus, having someone else do the work for you, means no aggravating phone calls or taking time out of your day researching and calling your creditors. To see if a medical bill advocate is right for you, fill out this form, for a no risk consultation.

Changes due to the healthcare reform.

Here is an excerpt from an online guide on what health reform means for you: “Recently enacted legislation will radically transform the U.S. health care system. These changes will occur over time, however. The most significant changes (e.g., a requirement that most people obtain health insurance) will not become law until 2014. A tax on employee “Cadillac” health plans does not take effect until 2019. This means there will be many elections and many opportunities for voters to express their will before most provisions become law. In the meantime, here is a brief summary.

Structural Features of Reform:

• Beginning in 2014, you will be required by law to have health insurance and to attach proof of insurance to your tax return.
• If you fail to insure, you will be fined — with the penalty rising to $695 ($2,085 per family) in 2016 or 2.5% of your adjusted gross income, whichever is greater.
• If your employer fails to offer you health insurance, your employer can be fined as much as $2,000 per employee per year.
• The type of insurance you must have — including copays, deductibles and the employee’s share of the premium — will all be determined by federal regulations, rather than by you and your employer.
• If you are not covered by an employer plan, Medicare, Medicaid or other government plan, you will be required to buy insurance in a government-regulated health insurance exchange, where competing insurers will offer the government-mandated health insurance benefit package.
• How your doctor practices medicine and how you obtain care are likely to substantially change.

Read more here in the online consumer guide.

Asthma, one of many conditions insurance companies can deny coverage over.

A pre-existing condition is a health problem that existed before you apply for a health insurance policy or enroll in a new health plan. It can range from something minor such as hay fever to a serious chronic condition like heart disease.

Insurance companies are concerned about their financial bottom line—it’s more risky to insure someone with a known condition– therefore it’s in their best interest financially, to exclude people with a pre-existing condition.

However, starting in 2014, the Patient Protection and Affordable Care Act signed into law in March 2010, no longer allows insurance companies to deny insurance coverage to adults, because of pre-existing conditions. (Effective September 2010, children below age 19 with pre-existing conditions may not be denied coverage.)

Do you know how much a doctor's visit costs?

Do you know how much a visit to a primary care doctor costs? Or a trip to a specialist? How about the cost of your monthly prescription? The average patient has no idea.

Many patients only have to pay a copay when visiting a doctor, specialist or picking up a prescription. Their insurance carrier pays the majority of the bill which prevents patients from the truth about how much they’re spending at the doctor’s office. As a result, most folks have no incentive and make little effort to be cautious about their health-care expenditures.

Consumer-driven health plans, also called a High Deductible Health Plans (HDHP) however address this problem, making patients aware of the actual cost of their medical visits.  A CDHC is a high-deductible insurance plan for catastrophic care combined with either a health savings accounts or an employer-funded health reimbursement accounts. (What is an HSA or HRA?)

A high deductible gives a patient a direct financial stake in the cost of their care;  giving them an incentive to search for the best deal. The prices of medical services can vary widely, so asking informed questions can dramatically reduce health costs. When patients are encouraged to consider the cost of procedures a huge savings in the cost of health insurance is seen. According to Research from the American Academy of Actuaries, CDHC plans are driving health costs down without sacrificing quality of care.

According to Real Clear Politics, “the typical CDHC plan results in first-year cost-savings of up to 15 percent.” While traditional insurance plans, where the costs are hidden, premiums have been increasing in cost each year.

Although, “critics of consumer-driven care say that it encourages patients to forgo necessary preventive care in order to save money.”  All the studies reviewed by the American Academy of Actuaries found that “patients received necessary care and that CDHC plans didn’t cause patients to avoid care.” In fact, all the studies found increases in the use of preventive care.

As the health-care debate continues, the largest challenge remains how to cut costs without sacrificing the quality of care. According to John R. Graham,  Director of Health Care Studies at the Pacific Research Institute, many have said that it’s just not possible. But a decade’s worth of experience with consumer-driven plans suggests otherwise.”

If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, preventive care services are now offered with out your having to pay a copay, coinsurance or meet your deductible when seen by an in network provider?  If you have questions on whether or not your policy falls under this new mandate, call the customer service number located on your insurance identification card.

Be sure to use up your FSA money before you lose it. Here are 5 tips with ways to help you spend down your FSA dollars.

1. Review the list of eligible expenses.

2. Make sure you have the medications and supplies you need. If you regularly take an over-the-counter or prescription medication, be sure you have an adequate supply on hand.  This may also be true for medical supplies, including contact lenses and solution, prescription glasses and even Band-Aids.

3. Schedule routine appointments. Make sure everyone in your family has received routine check-ups with their physician, dentist and optometrist.  If you see a specialty doctor, such as a chiropractor or acupuncturist, make sure you also visit them before the end of the year.

4. Get a flu shot and vaccinations. Be sure everyone in your household has gotten a flu shot and is up-to-date with vaccinations.

5. Invest in your wellness. Get back on track with your wellness goals now, and you’ll save yourself a lot of future medical expenses.  Smoking cessation expenses are eligible, as is weight-loss counseling with a letter of medical necessity.

6. Log your miles. You can be reimbursed 16.5 cents for mileage to and from eligible medical, dental and vision appointments.