Cry Babies Don’t Win…EVER
Ouch. Well, the truth is not always pleasant to hear, but it always helpful.
Whining and complaining to my friends and family may help me feel vindicated but such accomplishes nothing. I’ve seen it again and again—many of us have valid concerns and can very well appeal and win what is fair and appropriate. Sometimes this can be done quite easily and with really no actual resistance but what is in our heads. However, all too often, we simply commiserate.
This phenomenon will be a topic of another post, but suffice it to say right here and now: DON’T DO THIS.
Winners Take Action
It is kind of funny. If you want something and have the knowledge to get it, then quite naturally you must then take action. Cause and effect rules this world, not any of the victimization horse dung paraded about. And boy, there is A LOT OF THAT these days! Simply said, nobody is going to swoop in and save you. To the extent that such is true, there is always a cost.
Do you want to save yourself some money, to not get taken advantage of?
Well, then…DO something. I DID something.
This is what I did, and I will summarize with the most important details in an infographic for this post near the end:
I MADE A PHONE CALL.
Whoop de doo! How remarkable! It is sort of epic, right? I can see a major motion film being produced to celebrate this tremendous feat of courage. If you can’t tell, I’m being facetious.
Seriously though, sometimes picking up that phone and going about challenging an “official” decision can be nerve racking.
Before you go along thinking that I am some huge, egomaniac, hear me out.
I get it; I’ve been there. Who has not succumbed to that negative filter we all have in our head? But come on! Put this in its proper perspective. Making a phone call and challenging those little nagging shards of doubt and fear of confrontation in your mind does not have to be this big monster.
This truism is free of charge… Mark Twain once said that he “(…) had a lot of worries in [his] life, most of which never happened.” We worry about things that we simply do not need to be worrying about! Taking action eliminates fear and reveals it to be largely a fraud.
Back to the story…so I made that phone call, and no, celebratory trumpets did not blare. However, my heroism did not and could not end there! I did something beyond making that phone call.
I proceeded to use my words to communicate the exact problem, confirm some things that I already knew, and comfortably and confidently prove that the hospital bill I had in my hand was not legitimate and would not be paid.
Holy crap! This ain’t hard, huh? Now, there is a bit more detail than that, but I summarize that for you in the aforementioned infographic.
What was the result you ask? It was this:
The hospital bill was no more. This simple process took 10 minutes. And I saved myself $3000. It was like I rubbed a lamp and a magical genie transformed my problem into a key psychological victory. Something bad turned into something positive.
It worked for me, and it will work for you, should your circumstances be similar to mine.
END OF STORY
POST MORTEM OF THE BILL: AFTERWORD TO THE STORY
So that hospital bill I had lost its potential legitimacy. That did not happen, however, automatically. I had to do something!
It is important to examine these sorts of things. I know you really may just at least initially want the goods in this post, [and if you hadn’t thought of it, just skip ahead already ;)] much like how as a child we all want that dessert BEFORE the main course, but as with that meal, it is in the real meat and potatoes of the lesson that true nourishment or benefit is had.
You see, the details ARE important, and that is what I am about and what Sovereign Liberty Solutions is about. It is simply foolish and irresponsible of me not to do this post mortem.
That bill I had—I NEVER perceived it as being legitimate. I simply knew better. You can know better, too. This post will help.
However, let it be known that even if you perceive that something is not legitimate, that does not mean it simply resolves itself. No. I guarantee you that if I had not done anything, if I had not done anything with my knowledge and perception, I would have ended up getting collections notices and all that comes with that—in a sense, what was not legitimate, that bill, would have had very real consequences for me without my action!
Just what was that bill all about? THAT is the question most important for us.
First of all, as the infographic will demonstrate, we need to know, if we have insurance. [posts in the future will also discuss circumstances for those without insurance] We also need to know what our deductible, coinsurance, co-payments are as well as the standings in regards to such. Finally, we need to know the status of physician/facility [in or out of “network”] is, and then we proceed to verify that such, with the explanation of benefits from the insurance company, checks out in accordance to the benefits to which you are entitled under the insurance policy. Oh, and do not forget about the out-of-pocket maximum—this is just the way it sounds—you cannot be held responsible for anything at all over this stated figure in your health insurance plan.
Phew! That’s a lot of…crap. No, really, it is. I have empathy with you, really.
I know this stuff backwards and forwards for good reason. God knows that it IS boring. But you have to know this stuff and what it means.
I will create an infographic in the future that will assist you in defining the myriad of elements one may find in a health insurance policy. Until then, check out this little cartoon, which does a good job of doing this.
As tedious as that all was, in my story I did know all of these very important things. It turned out, after considering all of these things, that I should have owed $0—I had no deductible to satisfy as well as no coinsurance; I also had no copayment or any other fee to render under the authority of the insurance policy. However, I still had that big, bad hospital bill.
THE BILL HAD A NAME
Well, Bill is a terrible name. So let’s call that hospital bill I had BALANCED BILLING.
Yes, BALANCED BILLING is a terrible name, if we are thinking of naming a child. But in terms of identifying a common phenomenon in the wacky world of healthcare billing, such a name is exceptional.
You see, balanced billing is an actual practice. Now, without going too far into this, let me say that balanced billing happens with enough frequency, and prevails sometimes with certain “players” often enough, that I will not hesitate to say that it IS a practice. So this must lead to the inevitable: just what is this practice?
BALANCED BILLING: OR HOW YOU MAY BE BEING SCREWED
Ouch! Yup, that is some powerful language on my part. And I will not tone it down. To be honest, I am surprised that at this point more people, competitive business organizations included, are not more hostile to wrongs, misdoings, and the like. There’s actually a lot worse than balanced billing!
Now, don’t get me wrong, mistakes do happen. Of course; and this practice, which will be detailed in all its chicanery-filled horror, does happen, I am certain, by accident a good deal of the time. However, my experience, and common sense really, suggests that balanced billing is an intended and established PRACTICE.
Now is time to get down and dirty.
No, that was not an invitation. Get your head back in the game;) I know that this may amount to Chinese water torture [also going by other names these days] for you, but I promise that it is to your benefit.
Here is what it is, this thing called balanced billing:
You have an insurance policy, and it offers reimbursement schedules [to provider, hospital, etc.] and reimbursement allowances and shares of cost [to member/owner of policy] separated usually by “out of network” and “in-network” classifications, greater stated benefits to the member/owner/YOU contractually being in the “in” camp. We will focus on the share of costs, as it is the most relevant for us here.
In-network simply includes providers that have signed up to terms and conditions that are agreeable enough for both the insurance company as well as that provider. Out of network simply includes the rest.
To be in or to be out: that is the question
Why would a provider/hospital sign up to be “in” you ask? Well, I know you really didn’t ask this, but I will pretend you did. 🙂
By agreeing to the terms and conditions, said in-network providers gain access to a horde of individuals [including YOU; yes, YOU; YOU are part of the horde now] under that policy, a horde of individuals that come with, particularly, a group policy, which is what employers oftentimes offer to their employees.
Providers would do this to be assured of a certain likely quantity of patients, which means volume and a significant amount of money to be earned with patient visits; the other side to this agreement for the provider, the more negative side, is a contracted discount [among other conditions, restrictions, etc.] to be reimbursed by a combination of the patient/insurance member and insurance company. That combination payment and its percentage shares can be discerned by going through that mind-numbing terminology alluded to earlier. And, as always, remember that mistakes and illegal practices abound on all sides [not just with providers/hospitals, as is with my case and that typical of balanced billing]. Always be aware of what you are entitled to under contract and even statute!
Now we know that:
- A) Out-of-network providers and hospitals do not charge the patient/insurance member AND/OR insurance company a stated discount rate
- B) Being in-network constitutes a sort of advantage [only sometimes, as future posts will reveal] to the member/patient
FUSING STORY WITH INSURANCE STUFF: A TERRIBLE BUT NECESSARY CHIMERA
You may very well remember my story. The hospital that provided my services was in-network per the insurance policy I had at the time. This was VERY IMPORTANT in my analysis at the time. You see, you have to have a case to present. Whining or complaining and saying something is not fair will not work to your advantage in these sorts of cases; at least, it will not out of merit and as certainly as my way does at any rate!
Balanced billing can now be properly defined for you I think. Balanced billing is the occurrence in which the provider or hospital engaged in billing practices with the member/patient that is not in accordance with the contractual agreement established between the insurance company and that organization or provider.
More neatly and specifically for you:
Balanced billing is when the insurance company has paid less than what the provider has charged, which is usual and customary practice I have found [Innocently, it probably just saves time and resources for the provider/hospital, BUT, cynically, it also fetches some extra money due to insurance company or patient/member mistake or oversight] Balanced billing occurs when the remainder, or balance, is billed to you, the patient/member/customer.
So I was at an in-network hospital, and, as it turned out, the insurance company had reimbursed appropriately, per the contract between the insurer and hospital. I verified this with my three-way phone call that I had with my insurance company contact and hospital billing manager contact. That difference or balance between what was initially billed and actually paid is the $3000 I was being charged. BINGO.
Pst, I Have a Secret to Share with You
That’s right. Remember, I put in some time in the health insurance industry, several years. I realized that some providers/hospitals engaged in a whole lot of balanced billing, more than others. Now, if a provider/hospital is not following rules and abiding by restrictions and so forth as set in the contract with the insurance company, it is possible for the insurance company to terminate the provider’s status and dissolve the contractual arrangement. That would be a sort of consequence for mistreating the paying insurance company’s member [always remember, even if you do not pay out of pocket or only through paycheck deduction very little or none at all per month for the premium, that your employer pays for all else and that this adds up to a significant amount, an amount that no doubt reduces other benefits you receive as an employee!].
Well, as it turns out, I verified during my time in the industry, with one of the largest health insurers, that consequences often times were avoided. In other words, a violator, a provider that has at least the appearance of making balance billing an established practice, is able to continue the practice without consequence. The lesson here is obvious:
You need to be your own advocate with healthcare billing! You need to look at your bills from hospitals and providers as well as explanation of benefits forms [EOB’S] from third party payers such as insurance companies!
Here is Some Good News!
So that last section may have you a bit down or angry. Hopefully it hasn’t left you defeated, because you shouldn’t be. The thing is you have quite a bit on your side to stop this practice and prevent being looted!
Remember, balanced billing involves a difference between what was initially billed and what was paid by the insurance company, the difference, or balance, being billed to YOU. Now, EVEN if the insurer was wrong and should have paid what was being charged, the fact of the matter is that the insurance contract more than likely forbids the hospital from engaging in the balanced billing practice! This is NOT your problem at this point—it is a problem between the insurer and provider; and YOU must realize this and state it if need be!
Regarding balanced billing, health insurance companies submit plenty of letters advising participating [in-network; just another name for the same thing] providers and hospitals to NOT balance bill their members. They do this when the error or practice of balanced billing GOES NOTICED anyway. Not everything goes noticed—not such a subtle hint for you I hope.
ADDITIONALLY, strengthening your hand as customer/patient, nearly all states in the United States have state statutes on record that make this practice in most cases illegal!
So the private contract makes the balanced billing practice a no-no. The likely state statute makes it a double no-no. So you see, it is entirely in your favor to challenge ANY bill! That is GREAT NEWS! You have EVERY reason to challenge your bills and explore every angle, quite frankly.
So much is in your favor. Never, ever feel as if you are overstepping your ground or are “out of line” when working on these matters. I would advise strongly, though, to not be belligerent with anybody you may be communicating with in regards to your hospital bill or any other sort of bill—as always, be tactful while also being firm.
WHAT YOU HAVE BEEN WAITING FOR: THE BALANCED BILLING INFOGRAPHIC!
1) KNOW WHAT BALANCED BILLING IS:
Balanced billing is when the insurance company has paid less than what the provider has charged. That remainder, or balance, is billed to you. If the provider or hospital is “in network” this is likely not allowed and/or is even illegal
2) FIGURE OUT WHETHER YOUR PROVIDER OR HOSPITAL IS “IN” OR “OUT” OF NETWORK FOR YOUR INSURANCE PLAN
Be sure to know the proper designation. Also figure out the percentage share for “in” and “out” so as to calculate accordingly against the billing and explanation of benefit (EOB) information. 80-20 and 60-40 are most frequently used
3) DETERMINE WHAT THE INSURANCE FEES AND SHARES DO TO THE COSTS OF THE HOSPITAL BILL
DEDUCTIBLE: Any amount of healthcare charges billed to the insurance company below this amount is your sole responsibility. No coverage benefits are afforded to you until you exceed this amount
CO-INSURANCE: This is a percentage share between the patient/member and insurance company with regards to paying for healthcare bill. Betters terms usually exists for you when “in-network.” Coinsurance shares do not start until after the deductible is satisfied
CO-PAY: These flat fees are levied on a per visit/occurrence basis according to type of visit/occurrence
OUT-OF-POCKET MAXIMUM: You will not pay a cent over this amount. This comes when the sum of the deductible as well as your co-insurance share amount meets the out-of-pocket figure
4) COMPARE PROVIDER OR HOSPITAL BILLING WITH INSURANCE EOB
You may notice that the amount you are being billed PERFECTLY mirrors the difference [subtract the allowed amount from the billed] between the hospital billed amount and the explanation of benefits “allowed amount” [allowed amount per the contract between the insurance company and hospital]. If this is the case then you most likely are being “balanced billed.”
5) CONTACT THE INSURANCE COMPANY AND HAVE ALL FORMS AND INFORMATION READY
Make your case. Have the hospital bill as well as the insurance EOB in front of you. It is likely that the insurance representative will ask for contact information found on your hospital bill and set up a three way phone call. State your case for the hospital/provider billing manager as well if need be
6) FOLLOW-UP AT LEAST ONE MONTH LATER WITH THE HOSPITAL OR PROVIDER IF THEY DO RESCIND THE BALANCE BILLING CHARGES. ENSURE THAT THERE IS NO SNAFU
YOU ARE AWESOME
That’s right. You are awesome. Your neighbor may disagree and maybe even the postman, but that’s not something a stiff drink and a good dose of “I don’t care” won’t take care of right away.
It may be a real hassle, but knowing some insurance terminology and reviewing two billing related documents, while also being able and willing to make a phone call, can save you lots of money and even headaches and stress.
Just bear in mind that the healthcare related industries do a lackluster job in the billing and reimbursement departments for you, the customer. The last line of defense in these regards, in YOUR regards, is YOU. So this means that YOU need to take action once armed with information and a solid case—I hope I have helped you in these regards.
I admit that it is not a preferable thing, to have balanced billing and other healthcare related issues to pose such risks to your wallet—but the truth has to be confronted. Fortunately, if you spot these sorts of problems, it is very likely that between an insurance company service representative and hospital/provider billing manager you can settle potentially huge bills quickly and to your satisfaction.
WHAT DO YOU THINK?
Do you have any objections, thoughts, concerns, or contributions? I REALLY WANT TO KNOW. Help me to make this a conversation!
Together we can map out better solutions and truly navigate clearer paths towards quality services, low prices, and better lives.
Oh! And as always, if you find this post useful, do me and so many others a huge favor. When it comes to this kind of information: share and share alike! Information is meant to be disseminated wide and far.