Afraid Of Surprise Medical Bills? Here’s How To Avoid Them

Surprise medical bills have become a standard feature of American healthcare. Twenty percent of Americans say they’ve gotten an unexpected medical bill. The No Surprises Act was supposed to make surprise medical bills a thing of the past. 

But surprises happen all too often. A patient seeks (and receives) permission (also called prior authorization) from their insurer to get a particular service or treatment. Based on that permission, the patient decides to see a specialist, undergo a test or get a procedure or surgery. However, the patient learns after their treatment that the insurer won’t pay after all. 

In that case, the patient was not expecting the medical bill they get. It may be totally unaffordable 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 can’t prove that insurance promised to cover the bill. 

Sadly, patients experience this misfortune all the time. If this has happened to you, you may have felt completely powerless.

You are not powerless! There are steps you can take to help avoid paying hefty, surprise medical bills.

First, remember that insurance coverage isn’t always clear. 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 guidelines. Insurers absolutely have rules they need to follow. But your coverage is filled with many gray areas, which can leave 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 upfront effort could save you a lot of grief — and money — afterwards.

Steps to asking for a promise of coverage

1. 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.
2. Next, contact your insurer. Be confident! Instead of asking about coverage, state that you are calling to confirm coverage for an upcoming procedure. 
3. 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 you got from your provider. 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!
4. You may have to reiterate that the purpose of your call is to get “confirmation” (NOT 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. 
5. 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

1. ALWAYS ask for the name and contact information of the person who has confirmed your coverage. Hang on to that until you get your written confirmation.
2. 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.
3. If the insurer says they won’t send you something in writing, then ask for a supervisor. As long as your insurance covers the service or product, you are 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 contact information of the supervisor, too!)
4. 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)
5. If insurance does not agree to cover the procedure or prescription, you may be able to appeal their decision. Read your member handbook for the appeals process. Or, consider calling a private advocate to help you get your coverage approved ahead of time. A professional advocate can help save you time and money in the future. Hiring an advocate can be a great short-term investment that can deliver long-term savings.

These steps are widely applicable to many medical bills, and you absolutely have the 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, get help! Please don’t hesitate to reach out to a professional health advocate who can help guide you through this process. 

Find a Health / Patient Advocate or Navigator
Learn more about AdvoConnection and The Alliance of Professional Health Advocates