By Martine G. Brousse a financial advisor on NerdWallet’s Ask an Advisor.
One observation I routinely made as a billing manager, and still notice while auditing my clients' medical accounts, is that patients tend to fall into one of two categories. The "trusting" types promptly pay whatever amount is indicated, while the "questioning" ones rarely do until a final or collection notice is sent to them.
The former trusts the billing staff as much as their doctor, and the latter types tend to question any amount billed or wait for explanations (that they usually do not request).
It’s easy to fall into one of these camps, so here are some suggestions about when to pay and when to wait.
1. Check your insurance policy
The start of a new year brings lots of resolutions. This should go for your health care, too. Plan ahead for expenses by finding out how much you can expect to be responsible for that coming year. Know your yearly deductible (the sum you pay first before your insurer issues payment), as well as your yearly out-of-pocket costs (your percentage of the cost before your insurer pays 100%). Even a basic concern like if you have an office copay is good to know before heading to the waiting room.
Contact your insurer if your policy is unclear or confusing.
2. Verify and compare paperwork
Every amount listed on your provider's statement (from a doctor, facility, imaging center, lab, etc.) should match your insurance explanation of benefits. You may go online to check whether a claim has been paid and what you owe. If the statement's balance matches the EOB's, you are responsible for this amount.
Keeping a spreadsheet to track your statements and EOBs is a great visual help for you, and for your tax person during tax season.
3. If you have not received an EOB
Was the claim sent to your insurance company? More medical offices no longer handle this task, leaving the onus on patients. If you have been handed a claim form or an itemized bill, forward it to your insurance for processing.
A first statement may just be a notification or description of services rendered. Confirm that a claim has been processed before paying such a "notice."
Does the provider have your correct information? If you received a new card, forward a copy to the office; an identifying number or claim address may have changed. Charges may have been denied due to incorrect entries.
4. If your EOB does not match
Is the claim pending by your insurance? The EOB will indicate why. Additional information may be requested from you (an inquiry regarding other possible primary coverage, verification of dependent status, return of a health questionnaire) or from your medical provider (address update, medical records). In that case, forward a copy of your EOB to the billing department and demand prompt handling.
Consider calling the billing person to verify that contractual adjustments were correctly applied or to ask for justification. After all, mistakes happen. You may also contact your insurance company for detailed explanations.
Is the provider "out of network," meaning it’s not within the contractual network that your policy covers? If this is the case, you will need to negotiate a settlement, as you are liable for whatever amount is billed to you.
However, if services were rendered by an out-of-network provider at an in-network facility or setting, especially if you had no choice, an appeal to your insurance should be productive. Your insurer, once informed that you are being billed for the full amount, should likely propose a financial settlement or issue additional benefits to reduce, or pay off, your balance.
5. What are your rights?
In case of any conflicting or unclear paperwork, you are entitled, as a patient, to receive concrete explanations from your insurance carrier. You may also file an appeal, asking for a review or reprocessing of any charge. Detailed steps and specific forms are available in your policy booklet or online.
As your creditor, the medical office has the burden to detail and justify any charge billed to you. Although many do not – perhaps by choice or lack of understanding or training on the part of their staff – do not give up. A call or letter to the office manager or doctor will usually resolve such issues.
Filing a complaint to the carrier, a grievance to your state insurance commissioner's office or medical board is next.
Do your due diligence
While ignoring a bill from your medical provider is never a good idea, paying up without checking the amount billed to you is not recommendable either.
Your insurance should be your primary guide when determining if a bill is owed, and how much. Discussing charges with the billing department is your right to exercise whenever appropriate.