July 22, 2021

Anyone who has had an experience of a medical treatment is well aware of surprise medical bills. It’s unfortunate, but true. This is not just an Indian phenomenon, it is a global phenomenon. In fact, it has been estimated that globally, 22% of all medical emergencies end up with surprise medical bills. While your medical coverage may cover some of the cost, it is possible that you might have to shell out some money from your pocket, take a good decision to avoid surprise medical bills.

In this article, we will explain to you what leads to surprise medical bills, and how can the same be avoided:

Unplanned Treatments

While we plan for a lot of things in life, treatments are something that we cannot always plan for, unfortunately. Unplanned treatments are one of the biggest pathways to surprise medical bills. So how can you avoid surprise medical bills?

  • Check with the Hospital: We know that when a sudden emergency arises, our mind stops functioning logically. However, once you have avoided the initial turmoil, check with the doctor and the hospital about the tentative cost of treatment. Sometimes, you might get frustrated because they will probably not be able to provide you with useful information, however, believe it or not, humanity exists. Hence, there are chances that you might get a rough estimate of how much the bill is expected to touch.
  • Check with the Insurer: Once you have got a rough estimate of the cost, check with the insurer about their limits and sub-limits. Most medical insurance plans have specific limits with regard to specific treatments. Insurance providers usually have a 24 X 7 helpline which can provide you these limits and also guide you on what is included in your plan and what is not.
  • Get an Itemized Bill: Unfortunately, hospitals operate more as a business than as a welfare service these days. This is more true for countries like India, where Government support is poor and private hospitals are the only option left to the vast majority of people. You should definitely get an itemized bill and check and re-check if the bill is correct. In case you are unable to understand any item, take a clarification from the hospital helpdesk.

One word of caution. Although you might get an itemized bill, it is possible that the same is not what the insurer actually pays. The insurer might have a daily limit beyond which it will refuse to pay.

Planned Treatments

If you are going for a planned treatment, you will be mentally prepared about the same. Do the following to avoid surprise medical bills:

  • Check the Empanelled List of Hospitals and Doctors: Before proceeding for treatment, check the list of empanelled hospitals and doctors of your insurer to know if the ones that you are using is a part of the medical coverage. While it is important to use a hospital or a doctor within the network, do not compromise on the doctor. Most medical insurance plans provide medical coverage for out of network doctors as well, although the amount of such coverage might vary.  In this case, the difference between the actual bill and the medical coverage will have to be borne by you. This practice is commonly known as balance billing.
  • Check Medical Limits with Insurers: Most medical insurance plans have limits with regard to treatments. The limit for an angioplasty will differ from that of a cataract procedure. Moreover, most medical coverages come with a co-payment clause where the policy holder has to pay a certain percentage and the insurer pays the rest. Check all these limits with your insurer before going in for treatment. This will help you gauge the expected outflow of funds and avoid any kind of surprise in the future.
  • Get Estimates from Hospitals: Whether you are going to a hospital that is within a network or you are opting for a hospital that is outside the network, get an estimate of how much will the tentative bill be before going in for treatment. In case of a planned treatment, you will have enough time to do the same. Since most medical insurance plans have a co-payment clause, knowing how much you have to shell out from your pocket is good.
  • Manage Expectations and Arrange for Extra Payment: Finally, once you have an idea of what the bill will look like, arrange for the extra payment beforehand. Knowing from before will save you from the surprise of sudden unexpected bills.

Preventive Treatments

There is an old saying which says “It is better to be safe than sorry”. In case of health, this saying holds true to its core. Therefore, preventive treatments are something that every individual should go for. Fortunately, these days, most company medical insurance plans provide full medical coverage for preventive treatments.

However, by taking preventive treatments too you can land up with surprise medical bills. The treatment that you have taken may or may not be covered under the preventive treatment of your medical insurance plan or there may be a limit of coverage for preventive treatment. Hence, here are a few things that you should consider before going for a preventive treatment and avoid surprise medical bills.

List of Diseases under Preventive Treatments: Check with your insurer that the treatment you are going for is actually covered under preventive treatment. Often, surprise bills are received due to a miscommunication between insurer and the policyholder. Moreover, sometimes, doctors can add additional treatment as a part of the preventive care which may or may not be included under insurance. Speak to customer service executives for understanding the exact procedures covered under your policy.

Payment Methods: Check how a payment is supposed to be made while opting for preventive treatment. Clinics or hospitals and insurers usually have a tie up. The communication happens through codes, i.e. each diagnosis or a treatment has a code. The clinic keys in this code and sends the bill to the insurers. The insurers in turn follow the codes and release the payment. Surprise bills often arise due to input of wrong codes. Therefore, if you get a sudden surprise bill, do re-check whether the clinic has keyed in the specific disease and the same is received successfully at the insurer’s end. It might happen that due to the wrong keying in of the code, your treatment is not considered under insurance coverage.

Ask a senior claims examiner to recheck a claim to find out if the keyed in codes are correct. In case the insurer confirms that the keyed in code is wrong, speak to the doctor’s office and if required conduct a conference call between the insurance customer service executive and the clinic. While you may know that the codes are wrong, you may not know the specifics in which case and direct conversation will be helpful.

Each insurer has its own procedure. Therefore, it may also happen that the clinic is not adept to your particular insurer’s procedures and you end up receiving a wrong bill. Therefore, due to the clinic’s mistake, you are asked to pay for something which is actually covered under preventive treatment.

In case you hold a company health insurance policy, looping in the HR for help can be a good idea. Since the HR representative is a colleague, chances are that he/she will be on your side and try to help you out.

It is good to know what is covered and what is not beforehand rather than getting surprised at the last moment. Don’t wait for the last hour to start knowing your policy. Do the research beforehand, a little knowledge has never harmed anyone.

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