Medical Billing

8 questions to ask prior to a planned surgical procedure.

Prior to undergoing a planned procedure such as a knee replacement or gall bladder removal there are questions you can ask to help with calculating your out-of-pocket costs.

1. What is the exact name of the procedure?  Ask your doctor to clearly print the name of the procedure. Correct spelling is important and many surgery names sound similar.

2. What ICD-10 codes will be used? Your health plan pays healthcare providers based on these diagnosis codes, which the doctor’s office or hospital will provide to them. The coding system was recently updated from ICD-9 to ICD-10, which is much more detailed than ICD-9.

3. What is the CPT® code for this procedure? One or more five-digit CPT codes are the billing codes that are used by providers—usually for physician services—throughout the United States.

4. What tests will I need before the surgery? Blood tests, diagnostic imaging tests, such as a CT scan or ultrasound?  Ask for specifics about which blood tests will be ordered. Ask the doctor if you have a choice of facilities for getting these tests done. Check with your health plan before you have the test to find out where your out-of-pocket cost will be lowest.

5. Will other doctors be involved in my care and bill me for their services? A pathologist, a radiologist, and an anesthesiologist may be involved in your care. Even if your surgeon and the hospital are in your health plan’s network, other doctors involved in your hospital care may not be.

6. What kind of anesthesia will I receive? Many surgeries will involve care by an anesthesiologist and other doctors who may or may not be part of your health plan’s network.

7. After my surgery, will I go right home from the hospital? What medications and follow-up care will I need? After you are discharged from the hospital, you should be able to go directly home. After some operations, you may need care in a rehabilitation unit or skilled nursing facility for a while. Or you may need home health care. Your health plan can provide information about coverage and prices.

8. What else should I know about—such as potential complications—that might affect the cost of the procedure? For example a minimally invasive (laparoscopic) gall bladder surgery has to be changed to an “open” cholecystectomy, which may or may not be more expensive. You and your doctor should already have discussed this when you talked about the risks and benefits of the surgery. If not, be sure to ask questions about the open procedure before the day of surgery. Having a different procedure (or an additional procedure) is likely to change the cost. And if you need to stay overnight in the hospital for any reason, that is generally more expensive than an outpatient procedure.

Ultimately you may to call your insurance company (groan) or set up an online account on their web site (further groan). This may or may not give you an answer.  You could also wait for that Explanation of Benefits (EOB) statement in the mail – good luck with making sense of that document !

All of the above can entail a lot of time and effort on your part. The good news is that the whole process is a lot easier with new electronic tools that are now available. These tools do the math for you and calculate these costs. They also make your medical bills easier to read and decipher those confusing EOBs. Check to see if your employer offers these tools to their employees.

For more information on the tools offered by Obeo Health please watch the video on the home page.

In or Out of Network?

This article is reproduced from the HealthAffairs.org blog.  We at Obeo are tackling these very issues – helping consumers understand their medical bills and demystifying the EOB……

As co-workers and first-time moms-to-be, we shared much of the pregnancy journey together — including the same employer-sponsored health insurance plan. We even delivered within weeks of each other at the same hospital. For both of us, the key to managing the pain of labor and delivery was the epidural delivered by our anesthesiologists.

When it came to paying the bill, our hospital experiences diverged in one key way. Layla received an unexpected bill for $1,600 for anesthesiology services and warned Erin to expect the same. Yet Erin’s bill never came. Layla happened to deliver on a day when an out-of-network anesthesiologist was on call, while Erin was seen by an in-network anesthesiologist. Purely by chance, one of us received an expensive physician bill and the other did not have to pay a dime.

In the fog of new motherhood, Layla paid the $1,600 without question. She later received another unexpected piece of mail — a check for $1,040 from the insurance company to partially reimburse her for the anesthesiologist’s charge. The absence of a charge for Erin, and the check for Layla from the insurance company led us to suspect that Layla had seen an out-of-network provider. A call to the insurance company confirmed it.

Neither Layla’s statement of benefits nor the bill from her provider had stated that the $1,600 was an out-of-network charge. And she was still on the hook for the $560 difference, while Erin paid nothing for the same service. How was that possible? The answer, we discovered, was in the way insurance networks are structured and in how hospitals contract with physicians.

When ‘In Network’ Isn’t All-Inclusive

We both intentionally selected obstetricians and a hospital that were “in network,” thinking that we had done all the necessary homework when it came to orchestrating, and paying for, a planned hospital stay. As we would learn, selecting an “in network” hospital is only part of the puzzle for consumers negotiating the health care system.

Since the Affordable Care Act (ACA) was implemented, news stories have often described examples of hospital patients who have been hit with surprising and substantial doctor bills after being discharged. While the ACA includes provisions that limit out-of-pocket costs for patients seeing “in network” providers, the same protections are not extended to care received from out-of-network physicians — even when the patient has no choice in the matter.

Patients often aren’t made aware of this out-of-network policy until after they are discharged. Sometimes the physician in question wasn’t even there, which can be the case with radiologists and pathologists who read test results off-site. An out-of-network physician is allowed to bill patients for the difference between the amount charged for services and what the insurance company is willing to pay. For Layla, the difference was a few hundred dollars, but when surgery or emergency care is involved it can easily soar into the tens of thousands.

When out-of-network physicians treat patients at an in-network hospital and bill the patient for the difference, it’s called “balance billing.” It is illegal in Medicare to balance bill if a physician accepts Medicare patients, but the practice is allowed in other insurance plans, including employer-provided plans and those purchased through ACA marketplaces. It may be impossible in the moment to know whether a physician is in-network or out-of-network.

‘Excuse Me, But Are You Part Of My Network?’

Who would have the presence of mind during labor to ask whether the anesthesiologist on call is part of her insurance network? While providing patients with information regarding which physicians are in network is an important part of health insurance transparency, it is meaningless in situations where the patient has no choice. During labor and delivery, neither of us had any idea if more than one anesthesiologist was available, much less whether they were in-network. The additional out-of-pocket charge on top of the other labor and delivery expenses was left entirely up to chance.

Have You Recovered Enough To Decipher Your Bill Now?

A few months after delivery, Layla called her insurance company and was told that she was required to pay the charge because she “chose” an out-of-network provider. After making it clear that no choice was involved, she learned that the first step to having the service covered would be to request that the service be processed as in-network. She was also told to mark her “choice” of an out-of-network provider as involuntary. When that request was turned down, she filed a formal appeal that eventually went her way. When her baby was almost nine months old, Layla received a $560 check reimbursing her for the out-of-pocket costs. The transaction costs for this months-long back and forth were significant.

Expecting patients to decipher and pay unexpected and non-transparent physician charges in the days and weeks of recovery following a hospital stay places a substantial and unnecessary burden on the patient. When it comes to post-labor and delivery, a patient is also juggling the demands of a newborn and often experiencing increased financial strain due to parental leave from work.

national survey published in 2013 showed that the likelihood of involuntary use of out-of-network providers was higher among those with lower incomes and whose health status is “fair” or “poor.” This suggests that out-of-network charges are disproportionately impacting those who may be least able to dispute them.

Patients who have gone out of their way to ensure they receive care at an in-network facility should not be surprised by bills for involuntary out-of-network services. One solution would be to require that all providers offering care at an in-network facility are included in the plan’s network. Absent that, a few policy changes in the current system could be a step in the right direction.

Make It Transparent

Hospitals could have patients preregister for a planned stay and work with the insurance company to provide each patient with the estimated total expected charges. The estimates should incorporate all hospital and physician services, and account for possible variation due to intensity of services required or out-of-network services.

The key change here is that the estimated charges would include physician services for in- and out-of-network services. This approach would require the hospital to be straightforward with prospective patients regarding the likelihood of care being provided by out-of-network physicians. In turn, this may encourage out-of-network physicians to join the networks in which the hospital participates, since increased cost transparency may lead patients to request that they see only in-network physicians.

Make It Simple

Physician bills and insurance statements need to be simplified. While bills and explanations of benefits usually state the amount the insurance company won’t pay, they often don’t clarify that the charge is the result of out-of-network services.

Clearer explanations of charges, reasons the insurance company did not pay the full amount, and why the patient is being charged would help consumers better understand their bills — and help prepare them to pay them.

Make It Available

Researchers and policymakers have questioned the limited hospital and physician networks in the ACA health insurance marketplaces, as these networks provide access to a smaller set of providers.

Some states, such as Texas, New York, and Louisiana, are tackling out-of-network billing, whilelegislation was recently introduced in Congress that would place limits on the ability to bill patients for out-of-network services provided at in-network hospitals. It is encouraging to see that policymakers are trying to address the potential fallout from out-of-network physicians seeing marketplace enrollees at in-network hospitals.

Clearly spelling out expected health care costs, and the likelihood of out-of-network charges, would go a long way toward reducing the economic uncertainty associated with hospital stays — and help patients understand the billing statements they receive after discharge.

Can we make a better EOB?

If you’ve seen a doctor or been to a hospital recently, you’ll most likely have received what is called an EOB in the mail. EOB is short for “Explanation Of Benefits”. Every insurance company has a different EOB and many of them are difficult to understand.

Here’s an example of a typical EOB:

EOB_Original

Why do insurance companies send out these EOBs? An EOB is the statement insurance companies send you after your doctor sends them a bill. It tells you what the claim was for, what was covered, what you owe and why. But it’s not the actual bill.

Once you understand the purpose of an EOB, you’ll need to understand what it’s trying to tell you. This should be simple, but in today’s challenging world of healthcare pricing this can involve complicated math and unfamiliar terms. This is why Obeo Health created an EOB decoder, which provides consumers with an easy to understand breakdown of medical charges and how your benefits apply to those charges.

We start with a simple summary that includes the three most important numbers: what you were charged, what did your insurance cover, and what is your responsibility. Our tool then walks through the steps of how and why these dollar amounts were calculated, in language that is simple and easy to understand.

Finally, if there are any complicated calculations, Obeo lines up all of the charges so that you can easily understand how your total responsibilities were determined.

Here is an example of a visit to an ‘In-Network’ emergency room:

EOB_Blog

In a world where consumers are increasingly responsible for understanding the costs involved in their healthcare, Obeo Health is providing the tools necessary to make this information accessible and easy to understand.

Contact us to learn more about how Obeo Health can help your organization increase employee engagement in healthcare decisions and lower costs for everyone.