Medical Billing and Coding
- Advice for Consumers Facing a Major Medical Procedure
- The Difference between a Medical Procedure’s “Original Charge” and a Negotiated Rate?
- Uncovered Medical Services
- In-Network Vs. Out-of-Network Costs
- Help with Medical Bills
Medical bills can have a variety of components depending on the services received by a patient. There can include items such as:
- Doctor fees
- Facility fees
- Medication fees
- Medical equipment fees
- Lab fees
- Other service fees (e.g. anesthesia)
The various items on a medical bill should include the date on which the services were provided.
Like any billing system, mistakes can occur. Consequently, it is important for consumers to review their medical bills for accuracy and confirm the items listed on the bill reflect the services they received.
Bills from hospitals and doctors may use medical codes to indicate specific healthcare services provided to the consumer. These codes are normally 5-digit CPT (Common Procedural Terminology) codes. These codes were created by the American Medical Association (AMA) and are maintained by that organization. CPT codes not only indicate the service performed but can, in some cases, also indicate the time taken (e.g. a 5 minute doctor consult versus a 20 minute doctor consult). Normally, longer time periods are associated with higher consumer expenses. To confirm that they were charged the correct codes, consumers can look up the meaning of CPT codes online. Medicare has a similar set of codes to indicate healthcare services.
Advice for Consumers Facing a Medical Procedure
If you are scheduled to undergo a significant medical procedure that will involve hospitalization, it is a good idea to keep a record of the various treatments you receive so you can use these notes when reviewing your subsequent medical bills. Beware of duplicate charges within a single bill or across several medical bills.
Another way to spot errors with medical bills is to discuss the charges prior to a medical procedure. This information will provide you with a benchmark against which to evaluate your subsequent bill. Discussing charges before a procedure may also encourage you to comparison shop healthcare providers and hospitals and find a less expensive healthcare provider.
What is the Difference between a Medical Procedure’s “Original Charge” and a Negotiated Rate?
Doctors and hospitals can have multiple prices for the same medical procedure. For example, there is a standard rate that would be paid if no health insurance is used but there is a different rate Medicare or Medicaid pay for the procedure. Additionally, there can be another rate that an individual insurance company has negotiated for the procedure with the healthcare provider. Since insurers and government programs like Medicare have the benefit of scale, they have the leverage to obtain lower costs for medical services than would be the case for an individual.
Negotiated rates vary by insurance company. Typically these rates are around 30% higher than what the Medicare program would pay for the same procedure.
Uncovered Medical Services
An important thing for consumers to remember is that all medical services are not necessarily covered by your health insurance. For individual insurance plans, there are 10 Essential Health Benefits that include things like doctor visits, lab test, drugs, and hospitalization, but other services like gastric bypass surgery or infertility treatments may not be covered. See HealthPocket’s list of Top 10 Healthcare Services Not Covered Under Obamacare for more information.
In-Network Vs. Out-of-Network Costs
Finally, remember that medical charges are normally lowest for services received from healthcare providers that are in-network for your healthcare plan. Depending on your plan and the medical circumstances, medical procedures received out-of-network may be completely uncovered.
With the implementation of the Affordable Care Act, we are seeing a renewed interest in narrow-networks for health plans where fewer doctors and hospitals serve more patients in exchange for lower reimbursement rates from the insurer. Accordingly, consumers should be careful to confirm a healthcare provider’s participation in the consumer’s health plan network prior to receiving services.
Help with Medical Bills
There are a variety of resources to provide consumers with help with medical bills. Medicare recipients may be able to find assistance through the Low Income Subsidy (otherwise known as the Medicare Extra Help program). Those with low income may qualify for healthcare expense assistance through the Medicaid program.
Benefits.gov has a questionnaire that can help identify programs for which you may be eligible, including programs for assistance with healthcare expenses. Those people with disabilities should explore Disability.gov for programs that may provide assistance.