If you have engaged with the healthcare system for more than routine checkups, you have probably received a bill you don’t understand. Often, this is because the provider you visited was out of network, the procedure you received was not covered by your insurance plan, or simply the code your doctor entered in your invoice was incorrect. Below are some common instances that can result in an unexpected bill and ways to avoid pitfalls. RightWay Healthcare navigation can help skip the headache.
Going Out Of network
Going out of network can happen either intentionally or unintentionally. You might be forced under certain circumstances, or you may face unexpected hospital bills from a provider who turned out to be from out of network.
Circumstances for choosing to go out of network include the following:
Your doctor, who was once in-network decided to opt-out of your network, but this is a doctor that you trust to do the best job. She might be your obstetrician, and there's no one else you would trust more to deliver your baby. You are willing to pay more out of pocket for this service.
You may get a referral from your surgeon, who is in your network, to go to a radiologist, who is not in your network. After getting your X-rays done, you get a bill from your radiologist that you have to pay out of pocket.
The fine print in most can healthcare plans catch people by surprise. For example, in your insurance plan hospital expenses are (seemingly) covered. So you go to the hospital and end up in a private room, which is the only room available at the time. Later on, when the bill arrives, you find out that your insurance company doesn't actually provide coverage for "private rooms." You end up having to pay the same amount as you would if you didn't have any insurance at all.
So we see the problem with out-of-network services. If you talk to your Healthcare Navigator before seeing a doctor, having a procedure, or visiting the hospital, they will direct you to the best care accessible in your network. Here are some things they can do to ensure you will not get hit with an unexpected bill:
1) Confirm With Your provider
The purpose of contacting your provider is to verify what insurance they accept. While a provider’s website may list common insurance they accept, that may not include your specific insurance plan even if the company is listed. Navigators know the intricacies of each plan, what should be covered, and what questions to ask. They will confirm with the provider that they are covered under your specific insurance policy.
2) Review The Costs With You
Even if a provider is in-network, there are often costs you will still need to cover, such as a co-pay. Healthcare navigation companies can walk you through these costs. They may be simple, such as a $20 flat fee for all specialist visits. But they could be quite complicated such as 20% up to $3,000, 15% from $3,000 - $6,000 and free for anything over that amount. They will walk you through the breakdown and the amount you should expect to pay depending on the procedure.
3) Be Vigilant For Surprise Costs
Your doctor might be covered, but don't assume that anything your doctor orders for you will be covered as well. When she sends you to the lab in the other part of the hospital for a blood test, that service might not be covered under your insurance plan. If anything comes up during a visit, you can always call or chat your Navigator to understand the associated fees and if there are any cheaper options. For instance, it might be significantly less to get a blood test done at a freestanding facility versus at the hospital.
4) Look Into Gap Coverage
If you know that you will need a special service that's out of network, they can work with you to arrange for that coverage ahead of time. Even if the provider or facility doesn't normally provide coverage for that service, there may be a way to persuade your insurance company to cover it in the case of a special circumstance.
Rightway is a healthcare navigation company that is here to make sure that your care is covered. If you ever get a bill you don’t understand, you can send them a photo of it and they will walk you through it. If there are issues, they will contact your providers and insurance to advocate on your behalf and correct any discrepancies in the billing process.