I’m filled with dread every time I open my mailbox to find an “Explanation of Benefits” from my health insurer.
It’s bad enough when my portion of the tab is what I expected. But I virtually lose it when my bill is more than it should be.
A survey last month by Consumers Union found that nearly one in four Californians with private insurance faces surprise medical bills, in which the insurer paid less than expected.
Today, I’m going to give you some very simple advice to deploy if – and when – you receive a surprise bill:
This advice applies to people with Covered California or open-market plans, or employer-sponsored coverage.
It also applies to a broad range of surprises, whether you think you were charged too much for a procedure, wrongly penalized for going out-of-network or otherwise incorrectly billed.
“At least 50 percent of the time, you will prevail,” says Wendell Potter, a former health insurance company executive and author of “Deadly Spin,” an exposé about the health insurance industry’s practices.
“It’s very much worth it” to fight, he says.
Q: My insurance company billed me for going to an out-of-network doctor, but the same insurer told me beforehand that the doctor is in-network. What should I do?
A: It’s time to make some calls.
Many of you don’t realize you have appeal rights. Or you give up before trying.
In the Consumers Union survey, 40 percent of those who received surprise bills didn’t take action.
More than half of those said it was because they “didn’t think it would make a difference” and 18 percent said they didn’t know how to complain.
“People often are intimidated by the process of trying to get their insurance company to approve something that’s been denied,” Potter says.
Insurance companies know it and bank on it, he says.
“They know that people are not very savvy when it comes to dealing with insurance companies,” he says.
It’s time to get savvy.
Start with your insurer. The Explanation of Benefits will have instructions explaining how to contest the bill, or just call the customer service number on your health insurance card.
Insurance companies devote entire departments to consumer appeals and urge you to take action if there’s something amiss with your bill, says Nicole Kasabian Evans of the California Association of Health Plans.
“If you have a concern, or something looks or feels funny, challenge it,” she says.
If your appeal isn’t resolved within 30 days or you’re not satisfied with the outcome, go to your regulator, says Rodger Butler, spokesman with the state Department of Managed Health Care (DMHC).
I wish I could tell you there’s just one regulator for everyone, but in California, we have two state departments with authority over health plans: DMHC and the Department of Insurance.
(To complicate matters, for some people with employer-sponsored insurance, the U.S. Department of Labor is the regulator.)
To simplify, start by calling DMHC’s Help Center at 888-466-2219. DMHC regulates the vast majority of individual/family, small business and large-group health plans in the state.
“If you don’t know who to call, call us,” Butler says.
If DMHC is your regulator, you can move forward with the appeal process by phone or file your complaint online (www.HealthHelp.ca.gov). If not, the Help Center can connect you to the correct regulator, Butler says.
If you’ve gone through that process and you’re still facing a bill, go to the doctor, hospital or other provider where you received the service and bargain, suggests Julie Silas, senior attorney at Consumers Union.
“It’s worth picking up the phone and seeing if you can negotiate a reduced bill or payment plan with your provider,” she says.
I realize that fighting your insurance company doesn’t sound pleasant, especially if you’re sick and in treatment.
But you have allies.
“We can assist in the appeal process with the insurer so that consumers don’t have to do it themselves,” says Janice Rocco, deputy commissioner at the Department of Insurance.
I won’t deny that fighting an insurance bill requires time, effort and probably some frustration, even if you get help. But given the complexity of the health insurance world – and the dizzying pace of change – you need to be active and engaged in your coverage.
“This is an example of the changing landscape of health care where the consumer really needs to be their own advocate,” Kasabian Evans says.
Potter puts it another way: “It’s important to be a squeaky wheel.”
- Be persistent. “If you make one call and don’t make progress, call again and keep calling,” he says.
- Be organized. Note the time and date of your calls with customer service representatives, and the name of the person you’re talking to. If you mail documents, make a copy for your files first.
- Most insurance companies have executive teams that deal with “squeaky wheels,” Potter says.
“If you send a letter to the CEO, there’s a good chance that letter will be sent to the people who are dedicated to high-profile cases,” he says.
- If all else fails, he says, “you might hire an attorney.”
The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Located at the USC Annenberg School for Communication and Journalism, it is funded by the nonpartisan California HealthCare Foundation.
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