Surprise medical bills have become a standard feature of American healthcare. Twenty percent of Americans say they’ve gotten an unexpected medical bill. This isn’t supposed to happen, thanks to the No Surprises Act that are supposed to make surprise medical bills a thing of the past.
Consider how easily this can happen: A patient gets permission (also called prior authorization) from their insurer to get a particular service or treatment. With this assurance, the patient decides to see a specialist, undergo a test, procedure, or surgery. However, the patient learns after their treatment that the insurer will not be paying for the medical visit after all.
The medical bill is completely unexpected. It may also be way out of budget for the patient. The patient planned ahead and tried to prevent the bill – and thought they had taken care of it. Yet without written confirmation, the patient is unable to prove that their insurance said they’d cover the bill.
Sadly, this misfortune is all too common for patients. If this has happened to you, you may have felt completely powerless.
However, there are steps you can take to help avoid paying hefty, surprise medical bills.
First, it may help to know that things are not always clear cut with insurance companies. Sometimes the difference between getting an approval and a denial is just a matter of the day of the week, the time of day, or even the customer service representative you talk to.
That doesn’t mean your insurance plan doesn’t have parameters. Insurers absolutely have rules they need to follow. But your coverage is filled with many gray areas, which leaves it open to interpretation from one person to another.
The key is to seek a promise of coverage ahead of time. Before you get care, get that promise by calling your insurer. Then be sure to follow up the call with written confirmation.
Ideally, this process takes place weeks before you get medical care. Even if you don’t have that much time, seek approval as early as possible. This work on the front end could save you a lot of grief — and money — afterwards.
Steps to asking for a promise of coverage
- Begin by asking your provider what the “CPT” and “DRG” codes are for the services you need. A “DRG” (Diagnostic Related Group) is a code for your diagnosis. A “CPT” (Current Procedural Terminology) is the code that describes exactly what service or product you’ll be receiving, and what price is being charged for it. You might also ask what other information they can share with you, knowing you are calling to get your insurer to confirm coverage.
- Next, contact your insurer. Be confident! Instead of asking about coverage, state that you are calling to confirm coverage for an upcoming procedure.
- The insurer will look up your account to see which insurance plan you have. They will ask you which doctor has ordered your procedure to confirm that the doctor has a contract with the health plan. Then, you can give them whatever codes and descriptions were given to you by your provider to further that permission. Sometimes the doctor’s office has already supplied this information to the insurer because they are making some of the arrangements on your behalf. However, this doesn’t change your need and right to ask for a promise of coverage!
- You may have to reiterate that the purpose of your call is to get a “confirmation” (NOT a permission!) It is very important that you get this confirmation in writing! You can ask for a copy of the confirmation in writing either through email, mail, or via your member portal. Ask when you can expect to receive it and then check back to make sure you do.
- Finally, double-check that they have your email address and postal address correctly listed on your account or make sure you know how to get into your member portal.
More Tips to Avoid Surprise Medical Bills
- ALWAYS ask for the name and extension number of the person who has confirmed your coverage and hang on to that until you get your written confirmation.
- If possible, don’t undergo the test or procedure, or fill your prescription — whatever you’re waiting on permission for — until you have a written coverage commitment.
- If the insurer says they won’t send you something in writing, then you should ask for a supervisor. As long as the service or product is covered by your insurance, it’s within your rights to ask for a written confirmation and when you can expect to receive it. (Don’t forget to ask for the name and extension of the supervisor, too!)
- Finally, if you don’t receive your written confirmation by the date you were promised, follow up with the person whose information you’ve recorded. (#1 above)
- If they say no, meaning the procedure or prescription is not covered by your insurance, you may be able to appeal their decision. Read your member handbook for the appeals process. Or, consider calling in a private advocate to help you get your coverage approved ahead of time. A professional advocate can help save you in the future—a great short-term investment that can deliver long-term savings.
These steps are widely applicable to many medical bills, and it is absolutely in your right to get confirmation from your insurance company.
With proper knowledge and planning, you can avoid unexpected medical bills. If this process seems difficult to navigate alone, please don’t hesitate to reach out to a professional health advocate who can help guide you through this process.