Even though insurers assure you that preventive services (such as mammograms and colonoscopies) or certain elective procedures (like joint replacements) will be covered, you can end up seeing surprise fees on your bill for those very things. Don’t let that stop you from getting the care that you need to ensure you remain healthy. Read on to learn what you’re entitled to and how to get it without paying more than you bargained for.
One of the accomplishments of the Affordable Care Act (ACA) was to expand the roster of preventive medical procedures that any decent health insurance plan should cover at no extra cost to you—everything from wellness doctor visits to plan your healthcare to gynecological pelvic exams that help detect cervical cancer. Almost surely, whether you have insurance at work or through the ACA and Medicare, you are entitled to virtually all of the 30 most common preventive services for free. That includes:
- Blood pressure, diabetes and cholesterol tests
- Many cancer screenings, including mammograms and colonoscopies
- Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing sub- stance and alcohol abuse
- Regular well-baby and well-child visits from birth to age 21
Even still, fewer than one adult in 10 over age 35 gets all of his or her recommended preventive services. Men are less conscientious about this than women. Nearly 10 percent of men don’t get any preventive care at all. Not only can this lead to your health virtually catching on fire, if you do get sick with something that wasn’t caught sooner, the expenses can end up being astronomical.
Knowledge is power
When your doctor suggests a test, ask if it’s preventive or diagnostic, and why it is necessary. Unlike preventive procedures, you will nearly always have to pay something for
a diagnostic lab test. Costs can range from a $45 copay for a simple blood test to a 20 percent or more coinsurance for a $3,500 magnetic resonance imaging scan.
There are many ways you can learn about any suggested services and what is and isn’t covered: going to HR at work, asking your insurer or, if you have Medicare, calling 1-800-Medicare.
But no matter how you get your health insurance, the easiest way to get an in-depth look at preventive care and to ensure you know what to expect to pay out of pocket is to do a little research. You can start by searching “select a service” at CMS.gov, then selecting “preventive services chart.” It will show you all 30 common services, each with descriptions, current procedural terminology (CPT), or billing, codes and limitations. For example, for mammograms, there are no copays or deductibles for one baseline visit from ages 35 to 39 and annual screenings from age 40 and up, under CPT codes 77063 or 77067.
Once you have the information, you can call your insurance provider to double check that the test you need is covered. What’s key: knowing and mentioning the specific codes every time you book a preventive screening. This ensures that you’re not given any tests that aren’t fully covered. And if your doctor does spot a problem, you’ll want to stop him or her before they begin a formal “diagnostic” exam. Otherwise, you could get a surprise “diagnostic” bill before you have a chance to shop for your most cost- effective options.
So, say you’re booking a screening for prostate cancer, you’ll see that an antigen test (CPT billing code G0103) is free while a digital rectal exam (G0102) would cost you. So you tell your doctor’s office, “Please note that I’m coming in for a G0103, not a G0102.”
Elective surgery is not optional surgery. It simply means it’s not urgent — until it is. As the COVID-19 pandemic continues, your best bet is to put off any elective procedures for as long as you can, preferably to the second half of 2021. But, of course, if your back, hip or knees are causing unbearable and debilitating pain, you’ll have to act. In fact, 25 percent of elective surgeries demand immediate care, including compound fractures where the bone breaks the skin, bleeding ulcers, life-threatening heart conditions or a cancer diagnosis. Roughly speaking, about 25 percent of them, such as joint replacements for nagging pain and bariatric procedures for weight loss, can be delayed without harm. That leaves a debatable 50 percent where your quality of life is impaired but not destroyed, like painful varicose veins, gallstones or even brain surgery for mild tremors.
Proceeding with an elective surgery must be a joint decision between you, your specialist and the hospital. That said, there are ways to move forward to improve your life and protect your finances.
Vet your doctors and hospitals
Studies show that more than half of patients don’t get the right treatment plan. So always get a second opinion from a board-certified physician specializing in your specific condition. Board certification is the medical profession’s peer-reviewed seal of approval. Your insurer should give you a list of certified providers in your plan’s network. You also can check through the American Board of Medical Specialties (CertificationMatters.com or call 866-ASK-ABMS).
Check hospitals carefully too. At Medicare’s “Hospital Compare” page (at Medicare.gov/care-compare), you can judge hospitals’ “value” based on their charges and the crude measure of their death rates. Also, you can visit the Lown Institute’s excellent national hospital ranking at LownHospitalsIndex.org, which compares such factors as patient outcomes and satisfaction.
Compare your costs
Now, armed with your likely billing codes, as discussed in preventative care, call your insurer for the “contracted rate” for the top providers in your plan’s provider network. Staying in network will save you money. However, after carefully comparing providers, you may well decide that you can get your best outcome from an out-of-network provider. In that case, ask your insurer for the “usual and customary” rate for any out-of-network option you’re considering. That’s roughly the price your insurer has concluded most providers in your area charge for your procedure.
For example, if the usual and customary fee for your back surgery is $20,000, figure you’ll owe 30 percent coinsurance, or $6,000. But, let’s say the surgeon you prefer charges $30,000. In that case, you’d owe that extra $10,000, plus the $6,000.
Don’t hesitate to negotiate: Physicians and hospitals offer sizable discounts every day, sometimes based on patients’ resources and sometimes to get the business. One candid hospital billing professional in Utah said, “Any amount we accept from you is money that didn’t walk across the street to our competitors.”
Also smart: Go to the hospital’s ombudsman, a professional who’s paid to advocate for patients. Insist on getting any agreement you reach with them in writing, clearly addressing the services you expect, the costs and any payment plan you’ve worked out. Finally, consider paying out of pocket, especially if you have a high deductible to meet. Your provider might charge $2,000 for a procedure but will routinely accept 60 percent of that from insurers, or $1,200. He’s not losing a penny if he takes the $1,200 from you. He might even settle for $1,000 on the spot to avoid paperwork and wait- ing months for the insurer to pay.
Avoid sneaky fees
Before any procedures, nail down added costs, if any, for assisting doctors or other professionals, such as an anesthesiologist, and make sure they’re in network. It’s not uncommon for patients to expect to pay, say $6,000 for an in-network procedure and end up with a $100,000 bill by unanticipated out-of-network assisting surgeons. If you do get hit with a surprise bill, challenge it. Doctors and hospitals often accept less to avoid going to bill collectors who keep half of what they recover. And, studies show that half of all hospital bills have significant errors, like $10,022 for a trauma team that was never actually called in or being double billed for a “surgical kit and tray” and the same “knife and other instruments.” Or seemingly indefensible charges like $12 for a “mucus recovery system” (aka a tissue), $50 for one Tylenol or $100 just to turn on the operating room’s overhead light! These charges are often cleared up with one phone call, and if not, you can contact a patient advocate to fight for you.
Where to Find Billing Codes
To know what a procedure may cost or to ensure your bill is correct, these resources can help:
- TheAmericanMedical Association (ama-assn.org), which wrote the CPT codes, lists all 9,700 codes on their site which you can search using a CPT code or a key- word to see what the associated CPT code for a service might be. In order to search, you will have to register (for free) and you are limited to five searches per day.
- Clear Health Costs tracks medical costs by their billing codes in select cities. Visit ClearHealthCosts.com or call 914-552-9876.
Bringing Your Own Supplies to the Hospital
Hospitals charge inflated amounts for durable equipment—everything from walkers to CPAP machines. Here’s how to avoid those fees:
- Walk in with your own walker and bring your CPAP. Hospital technicians will make sure your equipment meets their standards. Assuming that they conclude that your prescribed CPAP for home use is delivering the right air flow to control your apnea, you’ll save money on the cost of renting a hospital unit.
- Need an arm sling? Buy a good one at a surgical supply store or on Amazon for around $13. If the hospital supplies it, you might owe $200 — a 900 percent markup.
- When it comes to medication, you’ll pay for every pill the hospital pharmacy doles out. However, they’ll usually allow you to bring pills from home that you take regularly for cholesterol, blood pressure, back pain and so on.
This article originally appeared in our print magazine, Save on Healthcare (Buy on Amazon, $12.99).