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Friday, 24 August 2018 10:30

Healthcare Claims Get Even More Confusing

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At Fall River we are committed to helping our members understand their health benefits and provider bills. We know that navigating the benefits world can be confusing, and unfortunately, we are seeing more and more claims situations that prove it’s getting ever more complicated. 

Here are recent examples of some complex and downright outrageous claims issues we want you and your members to be aware of.

  • Emergency room or urgent care?: Here on the Colorado Front Range, we’ve seen a spike in the number of new emergency rooms and urgent care centers during the past few years. That’s because they are huge money-makers. We educate our members to the fact that ERs are the most expensive place to get care and should be the last resort for treatment. Whenever possible, we try to direct them to less-costly and more convenient avenues of care such as contracted urgent care centers and telemedicine services. However, when searching for an ER versus an urgent care center, we’ve increasingly noticed that members can no longer rely on the signs outside the facility. We’ve run across numerous locations where the sign outside says “Urgent Care” but instead is billing as an emergency room, and the patient is surprised by unexpected charges later. To avoid this happening to your members, the best bet is to search on your health plan website for contracted urgent care centers in your area.

  • Out-of-network charges at an emergency room: Juliet wrote about this topic in our June Blog, but I wanted to reiterate it here. Essentially, patients in emergency situations are not responsible for any out-of-network charges included in the visit, and the health plan must pay them as in-network. However, we are seeing more often that patients are still being balanced-billed by the out-of-network provider for those charges above what the carrier paid out on the claim. Unfortunately, there is nothing in the Colorado law that prohibits these out-of-network providers from sending a bill to the patient, but members should be aware that they are not required to pay it.

  • In-network doctors not following contract rules: We’re also seeing more situations where in-network providers are not following the rules of the insurance plans they are contracted with. In a recent incident, a provider ordered $6,000 worth of lab tests but did not send those tests to a contracted lab. The member’s Explanation of Benefits (EOB) from the carrier states that the member is responsible for the charges, as the carrier’s position is that the member is ultimately responsible for making sure contracted labs are used. This is another confusing and unethical practice by in-network doctors and is not fair to the member by any means, but does bring up the importance of asking questions and advocating for yourself.

  • Pharmacy price surprises: If you are prescribed a new medication by your doctor, ask questions before you fill it. We’ve seen High Deductible Health Plan (HDHP) members be surprised to be asked for hundreds or even thousands of dollars to fill a single script! You may want to ask if it’s a brand name and if there is a generic equivalent that could reduce your out-of-pocket costs. We’ve seen several instances where a doctor has a practice of prescribing the newest medication available for a given condition. The problem is, doctors are in the business of treating your condition, not watching out for your pocketbook. Remember that generic medications usually cost much less and are the tried-and-true drugs that can most likely be trusted, as opposed to the new “designer drugs” that are being marketed to the public. Hint: if you’ve seen a commercial for the drug on TV, it’s probably an expensive one.

To recap, here are some rules of thumb that can help members avoid large out-of-pocket expenses:

  • Know before you go, and search for contracted doctors, urgent care centers, labs, and imaging centers in your area.

  • Investigate any unexpected provider bills, especially in conjunction with an emergency claim.

  • If your in-network doctor used an out-of-network lab or other provider, report the situation and the provider to the carrier’s fraud and provider contracting departments. If the carrier gets too many complaints about an in-network provider, they may sever the relationship with that provider.

  • Investigate your medication options, ask questions of your doctor and pharmacist, and choose a medication that fits with your treatment plan AND your wallet.

At Fall River we will continue to push for more transparency in the industry and are always on the lookout for ways to be proactive in educating our members. To learn more, or to start a member communication campaign, please contact your Account Manager.

Read 1925 times Last modified on Monday, 14 September 2020 11:33
Tonya Young

Tonya is our Senior Account Manager and brings eleven years of prior insurance company expertise to Fall River, having worked at Anthem Blue Cross and Great-West Healthcare (now part of CIGNA). Tonya holds a Bachelor of Science in Psychology from Texas A&M University. Originally from Minnesota, she loves the Colorado outdoors and enjoys family time with her young daughter.