Millions of people forgo needed medical attention — doctor visits, surgeries, prescriptions and testing — because they either lack insurance or the cost of using their policies is too great. It’s also complicated, a world of bewildering forms and websites, and seemingly unexplained denials of payment.
Before you delay care, consider ways you may be able to reduce your costs.
—Pay cash, rather than use your insurance. Let’s skip a deep dive into the insanity of how insurers pay medical service providers and jump to the reality: If you offer to pay cash rather than subject your medical provider (and you) to the insurance claim process, your bill might be slashed by 50% or so. Simply ask: How much if I pay cash? If you have a high-deductible hurdle to get past before insurance even kicks in and starts paying, going the cash route for office visits and routine tests can make plenty of sense, especially if you expect your total care costs this year might not exceed your deductible anyway. Talk to the billing department of any medical providers before a procedure to ask for the cash rate. If you don’t like the first answer, try again: “I don’t have insurance. What’s the lowest price I can get by paying cash?”
—Shop around, part 1: tests and procedures. We’re all creatures of habit, including your doctors, who often will recommend hospitals, clinics and specialists they are familiar with, or have a working relationship with. If that’s a level of comfort you highly value, then stick with it.
But if you are open to exploring what other options might be in your region, online sites can help you scope out local costs. The Fair Health Consumer website uses billions of data points from actual insurance claims to show zip-code level in-network and out-of-network costs for hundreds of procedures. That can give you a good starting sense of what costs are near you. If the price you are quoted is a lot higher, shopping around might be worthwhile.
The MDSave website says clients who access its network of nearly 300 participating hospitals in 33 states can save between 40% and 60% off of national costs. Clients pay cash, but can also pursue reimbursement from their health insurer.
Or pop your zip code into Healthcare Bluebook’s consumer website, choose a specific procedure, and the service will show you the range of local prices and what it considers to be a “fair price.” For instance, a recent search for a chest MRI in the Evanston, Illinois, area found standard prices ranged from around $660 to more than $4,250 with a fair price of nearly $1,200. At the same time, the service showed multiple places where the cost was half the fair price if you paid cash upfront.
—Shop around, part 2: meds. As nutty as it may sound, the cash cost of prescription meds you can buy online or by shopping around local pharmacies may be less than what those providers might charge you if you want to pay through your health insurance plan. The GoodRx website and app is a free service that shows you which pharmacies have the best deal for a given prescription drug. If your household has multiple meds that can be costly, it may be worth considering filling prescriptions through different pharmacies given that different pharmacies have different deals for specific meds. Be prepared for a blank stare from pharmacy workers when you present your GoodRx coupon; many are uninformed. But press on and demand the discount.
—Negotiate a payment plan. If you need extensive care that is going to generate high out-of-pocket costs (high deductible and co-pay) talk to the provider ahead of any care on whether there is a payment plan, say monthly or quarterly.
—If your insurer denies coverage, ask for a review. Given health insurers are businesses run for profit, there’s an inherent pressure to not greenlight every claim. Outside of emergency care, you always want to confirm with your insurer that a procedure will be covered. If you get turned down, time to put on your squeaky-wheel cape and insist on escalating it for review.
File this under motivation for not accepting the first no: A federal review of Medicare Advantage by the inspector general for the Department of Health and Human Services found that when consumers challenged initial denials, the insurer subsequently gave the greenlight 75% of the time. Yet in the same report, only 1% of patients asked for a review.
—For nightmare bills, bring in a pro. If you find yourself with a sudden illness that generates a tsunami of bills, or you are surprised to find out your insurer denied coverage (after the fact), you might want to bring in a medical bill advocate. These pros are skilled at deciphering codes, finding errors (not rare) and then negotiating with the provider to lower your cost, and/or negotiate a payment plan. The Alliance of Claims Assistance Professionals has leads on pros in a handful of states, and you can search for advocates at the AdvoConnection website.
Remember, you’re not alone in being challenged by healthcare costs and an inhospitable insurance system. The dollar amount of healthcare insurance premiums covered by employees, as opposed to the portion covered by their employer, rose 55% between 2008 and 2018, according to the Kaiser Family Foundation. That rate of increase was double the rise in worker wages. And deductibles — the amount you pay on a health bill before any insurance kicks in — more than tripled.
In 2019, the average household paid more than $6,000 a year in premiums for family coverage through a workplace plan. Deductibles averaged more than $1,600 for single coverage; families paid even more. When you actually need care, annual out-of-pocket costs for individuals with a workplace plan average more than $4,000. And that’s just if you stay in-network.
It’s worse for Affordable Care Act policies: In 2020 the maximum in-network annual out-of-pocket cost for individuals is $8,150 and $16,300 for family coverage. That’s on top of premiums.
In this environment, you need to know that healthcare providers are accustomed to negotiation on price and payment terms.
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