Don't pay that medical bill before carefully reviewing it

If you like horror stories, I recommend a series on National Public Radio, “Bill of the Month.” Listeners can send in a surprise medical bill, and NPR and Kaiser Health News investigate.

One family was hit with a $19,000 bill after their son fell off his bike and needed sutures. A woman in New York was astounded that her doctor billed her insurance company nearly $26,000 for a strep test.

It's easy to attribute these stories to out-of-control medical costs, providers who charge whatever the market will bear, and insurers who look for any reason to deny a claim. While some of that is true, the reasons your medical bill is what it is are complicated and difficult to for the layperson to understand.

But knowledge is power. You can arm yourself with information that may end up saving you thousands of dollars. Here are some tips:

1.) Understand your health insurance coverage, and don't be afraid to ask questions. Know what your deductibles, coinsurance, copays and out-of-pocket maximums are. Ask why your doctor is ordering certain tests or recommending certain procedures, and call your insurer to find out how much you'll be asked to pay. Write down the answers to your questions and who you spoke to on what dates. Get promises in writing. And if you're uninsured, be upfront about it.

2.) When you receive a hospital bill, never pay the full billed charges. First, make sure it's an actual bill and not just a statement saying insurance hasn't been applied.

When you get the bill, call and request an itemized bill (which you may have to request more than once). According to Illinois Legal Aid, a hospital bill must include the following:

• The dates of services you are being billed for.

• A short description of the services.

• The amount you owe.

• Information on how to contact the hospital if you have questions about your bill.

• Notice that you can get an itemized (more detailed) bill.

The itemized bill should have a line-by-line list of the charges; the associated “revenue code” (the internal code the hospital uses to determine their charge); and the insurance codes that describe each line item. Compare this with your insurer's explanation-of-benefits (EOB).

If you feel a charge is out of line, online claims-data websites, such as Healthcare Bluebook and Fair Health, will help you research what insurers pay in your area for similar procedures. You may be able to use that information to negotiate your bill. You may be invited to apply for financial aid at this point, but unless you're satisfied the bill is accurate, don't apply just yet.

3.) Be on the lookout for “balance billing.” This is what happens when you receive care at an in-network facility but one or more of your providers (like a pathologist or anesthesiologist) is not in your network. All of a sudden, a procedure you thought was covered generates a balance bill. Ask which lab will be used and who the other practitioners are to make sure they're in your network.

The good news is that balance billing is illegal in many states, including Illinois. The Illinois Balance Billing Law states that out-of-network, facility-based providers are prohibited from billing patients for expenses other than the deductible and co-pay they would have normally paid if they had seen an in-network provider.

But that only applies to state-licensed plans. If your employer's insurance is self-funded, you may still see a balance bill. Insurance and medical industry lobbyists have stymied a federal solution that would cover everyone.

4.) Don't simply ignore a big hospital or medical bill just because you have questions about it — or you're hoping it will go away. It won't, and hospitals are relentless when it comes to collections. Keep the lines of communication open so the provider and your insurance company know you're working toward a solution.

5.) Get help if you need it. Fighting a medical bill is exhausting even for the most determined. If the bill goes to collections, it may impact your credit score. There are companies that will go to bat for you for a flat fee and a share of how much they reduce your bill. Patient advocates, who typically have medical backgrounds, can help you make sense of an itemized bill and perhaps identify potential savings.

Sometimes the surprise of an unexpected medical bill is worse than the bill itself. Do some homework ahead of time — even for an emergency room visit you can quickly see what your co-pay should be. You will save yourself some sleepless nights and maybe money, too.

• Teri Dreher is a board-certified patient advocate. A critical care nurse for 30+ years, she is founder of NShore Patient Advocates ( She is offering a free, 30-minute phone consultation by calling (312) 788-2640 to make an appointment.

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