Understanding your health insurance policy can be tricky, but knowing the terms of your policy before a medical professional treats you is the key to helping you avoid unexpected and often hefty bills.

The staff members at eHealthInsurance.com, a website that helps consumers find health insurance, frequently field questions about health insurance policies. They have seen quite a few complaints from people who thought a healthcare provider took their insurance but who found out they weren’t covered in the way they thought after they received a bill.
There are two typical scenarios that often occur. Some patients may find that a member of a medical professional’s office staff said that their insurance policy provided coverage, but it actually did not. Other times, patients simply didn’t understand their insurance coverage when facing a test, a service, or any procedure other than a regular doctor visit—and they received a bill for which they weren’t prepared.

Coverage for office visits

Keith Mendonsa, consumer health insurance expert at eHealthInsurance.com, said, “There are lots of dentists and optometrists who will be glad to accept your insurance and submit the bill to your insurance company. This doesn’t mean, however, that they are in-network and contractually obliged to accept a certain dollar limit, which may be less than their full charge, as payment in full.”
Unfortunately patients who find out too late that they were not in-network have limited options.

“In the end, it’s always considered the patients’ responsibility to make sure that they’re seeing network providers,” Mendonsa said. He added that a 2012 provision of the health reform law requires health insurance companies to make summary of benefits and coverage forms available for the plans they sell, which may help patients looking to better understand their coverage.

“These are standardized forms that answer a number of basic—and not-so-basic—questions about what policyholders should expect to pay for specific medical services. If you haven’t already received one of these forms from your health insurance company, ask for one,” he said.

Your best bet is to call up your insurance company ahead of time, make sure you completely understand your coverage, and verify that a provider is in-network, even for small things like co-pays. For example, some office staff will take you at your word when you say you think your co-pay is $35—when actually it’s $25—and then not uncover the error in a timely manner.

Coverage for medical procedures

Patients can also get hit with unexpected medical bills when a doctor orders medical tests, services, or procedures that go beyond the scope of a simple office visit. Typically, these bills crop up when patients don’t understand for what they’re personally responsible in terms of co-payments and deductibles.

“X-rays are generally covered, for example, but if you haven’t met your deductible for the year, you may end up paying for [them] out of pocket,” Mendonsa said. “That said, if you’re at the doctor’s office or hospital and a specific procedure is being ordered for you and you’re concerned about whether it will be covered at all, you can certainly contact your insurance company or ask the doctor’s office to check with the insurer on your behalf.”

What to do if you’re hit with a medical bill

Unfortunately, if you’re stuck with a bill for something you thought was covered, you don’t have a lot of options.

If you can’t pay the bill right away, contact the hospital or billing department to figure out what you can do before it’s too late. Some hospitals and doctors have patient advocate services to help you navigate health insurance policies, procedures, and bills, so start there. If the bill is bigger than you can afford, request a cash discount or ask to set up a payment plan. But above all, do not ignore the bill. If you don’t pay, it could wind up in collections.

TIP: Have you checked your credit score in the last year? Pull a copy of your credit report from AnnualCreditReport.com to see if you have any medical bills to pay.

Michelle Stoffel Huffman is a researcher and staff writer for Think Glink Inc. Prior to joining Think Glink, Michelle worked for the Chicago Tribune as a daily news reporter and community manager, covering local government, business, tax issues and crime. She now specializes in real estate industry news, consumer financial reporting and home design and decor. She is a graduate of DePaul University in Chicago.

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