Terminology
Allowed Amount / Negotiated Rate: The most that your insurance plan will pay for a service. If your provider charges more than the allowed amount, you may have to pay the difference.
Balance Billing: When a provider bills you for the difference between their usual charge and your insurance plan’s allowed amount. For example, if the usual charge is $100 and the allowed amount is $70, your provider might send you a bill for $30. Many states, including California, prohibit balance billing from in-network providers.
Coinsurance: Coinsurance is the percentage of the medical bill that the patient pays after they’ve met the deductible. The rest is paid by the insurance company. For example, if you have a $5,000 deductible and 20% co-insurance, and you receive a $10,000 hospital bill, you will be responsible for paying $6,000 ($5,000 deductible + (20% of the remaining $5,000, which is $1,000).
Copay: The copay is a “shared” payment for in-network services provided. Usually, copays are between $20-50 for doctor visits.
Deductible: The deductible is the amount of money the insurance company requires the patient to pay out of their own pocket before the insurer will start paying. This can range from a few hundred dollars to many hundreds of thousands of dollars. Typically, the higher the deductible, the lower the premium - but the more risk you as the patient will be taking.
Explanation of Benefits (EOB): An EOB is a statement from your health insurance company describing what costs it will cover for the medical care you received. The EOB is generated when a claim is submitted (either by you for out-of-network services or by your provider for in-network services) for the services you received.
In-Network: The facilities, providers, labs, hospitals, and pharmacies that your health plan has contracts with to provide health care.
Non-Covered: Insurance plans may not be required to cover certain services or services provided by certain providers, even if the provider is in-network.
Out-of-Network: The facilities, providers, labs, hospitals, and pharmacies that your health plan does not have contracts with to provide health care and that, therefore, are not covered under your plan unless you have partial out-of-network coverage.
Out-of-Pocket Maximum / Limit: The out-of-pocket maximum is the maximum amount of money that the customer/patient needs to spend in deductibles, co-payments, and co-insurance in a given year before the insurance company will cover everything. This is usually a round number and can be as high as $20,000 or more (which means you would need to spend $20,000 before your insurance company covers the rest). Once you hit this, your insurance plan covers all of your medical expenses.
Prior Authorization / Preauthorization / Pre-Approval / Prior Approval: A prior authorization is an insurance plan’s requirement that your provider submit documentation proving the medical necessity of a particular service or treatment. Insurance companies use prior authorizations as a tactic to delay and deny patient care in order to raise profits and shareholder value.
Premium: The premium is the amount that the customer/patient pays the insurance company in order for the insurer to cover you. This term is usually referred to as a ‘monthly premium’ or ‘annual premium.’
Getting Organized to Tackle Insurance
Track down email address for insurance company customer representative. Communicating with customer service representatives (sometimes called “client service consultants”) via email rather than phone can be more productive, save time and energy, and it creates a record of your communications that you can easily track. If you obtain health insurance through your employer, you can ask your employer to ask their insurance broker for this contact information.
Copy/scan all superbills, claims, and documents sent by your insurer. Save in specified folders.
For documents returned by your insurer, I recommend saving in a format such as: “[insurer][date on document]_[Doctor’s name][date of service]. For example, Cigna 2.2.22_Dr. X 1.1.22.
Find a Human at Your Insurance Company
Calling your insurer’s customer service number might help, but this process can be incredibly time-consuming and you may get bounced around from one rep to the next and receive conflicting information from each person with whom you speak.
Often, a more efficient and effective approach is to find someone at your insurance company who you can communicate with via email.
Customer Service Representative
If you have insurance through your employer, you can ask your employer to ask their insurance broker for the email address of a “customer service representative” or “client success representative.” If you feel the need to justify your request, you can explain that your insurer is not covering your care as it is supposed to under your plan and that in your experience, it is easier to resolve these issues when you have a direct contact with whom you can communicate with email.
Public Relations Contact
Insurers respond to negative media attention - or even the threat of media attention. It would be nice if we could all get our care covered without resorting to putting our stories on blast for the whole world, but sometimes that’s the key to getting care covered. Connecting with someone in your insurer’s PR Department can be effective for getting your previously denied or delayed care covered.
Search LinkedIn and/or Google to find the name and contact information for someone who works in your insurance company’s Communications/PR Department. Email them or send them a message on LinkedIn. Explain to them in simple, direct terms that you have an insurance matter that you’re having trouble getting resolved and that if it is not resolved promptly, you will go to the media.
You can also bring in a journalist to make this connection for you. When journalist’s reach out to insurer’s to inquire about a story related to coverage denials, it puts the insurer on alert and it can be a good way to get your care covered.
***If you are a journalist or are connected with journalists who would be interested in joining our community to advance our efforts to get patient care covered, please reach out to Hello@IAMTHEBOTTOMLINE.COM.
Media Storm
Health insurance companies want to stay out of negative news stories to protect their brand. If your struggling to get your insurer to cover the care you are owed, publicize your story. Share your story through petitions (it’s easy and free to create petitions at Change.org), traditional media, and social media. You want to get as much attention on your story as possible.
Share your story with I AM THE BOTTOM LINE. We’ll blast your stories out to the world, and we’ll need our community’s help to do so! We’re all in this together!
In-Network vs. Out-of-Network
It’s important to understand the terminology around “in-network” and “out-of-network,” how to read medical bills, and how to get reimbursed for out-of-network services if that’s available to you under your insurance plan. Understanding how insurance works and having a system in place for navigating the insurance claim process gives you the best chance at getting reimbursed, and hanging on to as much money as possible.
In-Network v. Out-of-Network
Insurance companies negotiate pricing agreements with healthcare providers. In-network providers have established pricing agreements with your insurance company. Providers that have not established these pricing agreements with insurers are considered “out-of-network.”
Out-of-Network Billing Costs
Out-of-network care is generally more expensive because the price is higher and the insurance covers less of it. Even if your provider charged the same amount as an in-network provider, your out-of-network benefits aren’t as good and you would have to pay more of the bill yourself, out-of-pocket. For example, even a really great insurance plan that has a $20 co-pay for seeing an in-network doctor will make patients pay at least 30% co-insurance if they see an out-of-network doctor. Many insurance plans will make you pay an even higher percentage than that.
On top of that, out-of-network care usually costs more than the insurance company will admit is reasonable. Out-of-network providers haven’t had their fees negotiated down to what your insurer is willing to reimburse - in some cases they don’t take any insurance at all. You have to pay the difference between what the insurance company deems a reasonable fee and what the provider has charged/deemed a reasonable fee. This difference between what your insurance plan pays and what you were charged by the out-of-network provider is called “balance billing.”
How to Handle Out-of-Network Bills/Costs
Negotiate with the insurance company and hospital, working to get them to agree on an “in-network” rate. First, you will need to convince the insurance company that the bill represents a financial hardship and you had no option but to go out-of-network. Second, you will need to convince the hospital that the in-network rate will provide them the best financial outcome.
How to Submit Out-of-Network Bills (Superbills) to Insurance
Ask your out-of-network provider for an itemized superbill.
A superbill is different from an invoice because it includes diagnostic and procedural codes, which are required to get a claim approved by insurance.
For each procedural code, your insurer has an amount that they will pay and a list of diagnostic codes that allow a provider to perform the procedure.
Submit the superbill, along with a filled out claim document, to your insurer. You can do this online or via snail mail; the claim document will be slightly different for each insurance company, but they should all contain the same information. If you submit online, the claim document may be automated from your account.
Most insurance companies are run by slimy, greedy devils and will make it as hard as possible for you to be reimbursed. They may initially either deny your claim, or repeatedly send you letters stating that you didn’t include necessary information or that the information you sent was distorted (and if it wasn’t, they’ll run it through the fax machine until it is). Stick with it. We can win this fight!
If you receive letters from your insurance company in response to your claim submission, make a photocopy or scan the document. It’s important to keep records. Review the document, and make sure that, in fact, you did include everything you needed to.
If they say that the documents are illegible, resubmit them after confirming that the documents are legible.
If they say that the procedure code is not supported by the diagnostic codes, you will need your provider to re-generate your superbill with the missing diagnostic codes that support the procedure code.
If they say that there was a cheaper alternative that should have been tried first for the diagnostic code, you will need your provider to write an explanation for why the cheaper alternative was not an option for you (e.g., you’ve tried it before and it gave you anaphylaxis, it’s contraindicated because of your conditions, etc. )
Contact your insurance company’s customer service representative. I recommend obtaining the email address for a customer service representative because in my experience, this approach is more efficient and effective, and requires less time and energy on your part. If you are insured by your employer, you can ask your business’s insurance broker to provide you with the direct contact information for a customer service representative who is able to assist with your account.
Email your customer service representative, explaining the errors or issues at hand. Attach the letter you received from your insurer and a copy of the superbill.
Medical Claims
A medical claim is a bill that healthcare providers submit to patients’ insurance companies. Medical claims contain medical codes detailing the care administered during a patient’s appointment. The medical codes describe the services that a provider rendered, including: diagnosis, procedure, medical supplies, medical devices, pharmaceuticals, medical transportation.
Medical claims are organized in two parts: (1) Claim header, and (2) claim detail. The claim header summarizes the most essential information in the claim, including confidential patient information (e.g., date of birth, gender, zip code), National Provider Identifier (NPI) for the provider and service facility, primary diagnosis code, inpatient procedure (if applicable), diagnosis-related group (DRG), name of patient’s insurance company, total charge for the claim. The claim detail includes information about secondary diagnoses or procedures, date(s) of service, procedure code(s), corresponding diagnosis code(s), National Drug Code (NDC) (if applicable), provider NPI, service charges.
Insurance companies assess the medical codes to determine if/how they will reimburse a provider (or patient, if the provider is out-of-network) for the services rendered. Sometimes insurance companies base these assessments on the patient’s insurance plan, and sometimes insurance companies claim (re: LIE) that the services aren’t covered in the patient’s plan.
Medical Coding
Medical claims must include certain codes in order for the provider (if in-network) or patient (if the provider is out-of-network) to obtain reimbursement for the services rendered. You can Google the codes that are listed on your medical claims to make sure you understand and agree with the services listed. Providers and billing departments make mistakes, and it’s important that you know how to research the codes to make sure you aren’t being incorrectly billed.
Current Procedural Terminology (CPT) Codes identify medical services and procedures provided.
International Classification of Diseases (ICD) identify patient diagnoses.
Healthcare Common Procedure Coding System (HCPCS) is a code set developed by CMS for reporting medical procedures and services; it is based on the CPT coding system. HCPC codes are a standard for representing medical procedures to insurers. Level I HCPCS codes are identical to CPT codes; Level II HCPC codes are primarily used to identify products, supplies, and services not included in CPT codes (e.g., ambulance rides, wheelchairs, walkers, etc.).
Prior Authorizations for Medication
This formula doesn’t always work - you might need to get more creative, but it works frequently enough that it’s worth a try!
Search Google to find the insurer’s coverage policy for the drug in question (e.g., search "Cigna coverage policy Motegrity").
Review the insurer’s coverage policy document to identify the "criteria" (which usually means, what drugs does Cigna require the patient to take before being allowed to try the drug you want the patient to take - and what criteria must be met in order to be able to take that drug).
Google "FDA Access X" (X is whatever drug the coverage policy wants the patient to take instead of the drug you want the patient to take). This search will bring you to the drug’s “label.”
Review the label document to identify the "indications" - and assess whether or not they line up with the indications of the drug you want your patient to take.
Review the document to identify the "warnings," "precautions," "contraindications," "adverse reactions" - and assess how those considerations line up with your patient's health situation (e.g., if the drug may cause hypotension and syncope, and your patient has POTS, you can use that info to explain why the drug recommended under the coverage policy is not a safe option for your patient).
Google "FDA Access Y" (Y is the drug you want the patient to take). Make sure you are not using an argument that would also apply to the drug you want the patient to take (e.g., if both X and Y drugs list syncope as a contraindication, don't argue that X isn't an option bc your patient has POTS).
Claims File
When a health insurance company is deciding whether or not to pay for your medical services, the company generates a file around your claim. All the records associated with your case are part of your file, including documents explaining why they denied your claim and the anticipated cost savings associated with denying your claim. You have a legal right to obtain your claim file. Insurers don’t want you to know that. You can use this generic claims file template to request your files (or this one for Cigna or this one for Elevance Health).
To learn more about claim files and how to navigate this process, read ProPublica’s reporting on this important issue and use ProPublica’s tool to request your claim file. (thanks to ProPublica for all your hard work!).
Insurance Appeals
Insurance companies have strategies and algorithms to deny as many claims as possible. Their goal is to not cover the services you need, and their success depends on patients and caregivers not fighting back. FIGHT BACK. You need to understand your insurance plan, the terms insurance companies use, and how to argue your case. Read Health Law Advocate’s Guide to Appeals to learn how to fight back - and WIN.
Manage Your Medical Bills
Financial Assistance
Financial assistance programs may be available for your tests and/or treatments.
Some insurance companies won’t proactively inform you about financial assistance programs; they rely upon you to tell them that you can’t afford the service(s) you require before they’ll inform you of options for financial support. Ask your insurer if they offer financial support or coupons for any of the medications you take - and be specific.
Medical providers may also have financial assistance programs. Ask to speak to your provider’s billing office and request a written copy of their financial assistance policy. If they offer financial assistance, ask for a Financial Assistance Application.
Medical bills may mention “financial assistance programs.”
Non-profit hospitals are legally required to provide financial assistance. Ask to speak to the billing office.
Scrutinize Your Bills
Review and scrutinize your bills. Learn what the terms and numbers mean. Medical bills frequently contain errors. If something doesn’t seem right or you’re confused about how something adds up, ask questions. Don’t assume they’re right and you’re wrong. MAKE A FUSS.
Negotiate Your Bills
Explain to your providers your financial situation. Get personal. Share your story. Make them care. Ask for discounts. Ask for bill forgiveness. Build relationships with billing managers; get them on your side. Before opening up your negotiation, consider how much you can pay per month for each bill. Make sure to get any negotiated agreement in writing, whether it’s a discounted price, bill forgiveness, extended plan, or anything else. If you do agree to an extended payment plan, request monthly statements that record payments and the remaining balance. Keep track of your payments and receipts until the debt is paid off.
Below is some suggested language:
“I would appreciate if you could reduce my charges to the negotiated rate - the amount that private insurance companies, Medicaid, or Medicare would pay for the same service(s).”
“I’m unable to afford the cost of these services.”
“I’m unable to pay all of my bills at once.”
“Can we settle my account for a discounted price? I can afford to pay $__ per month.”
“Can we agree to a longer payment plan? I can afford the full price, but I need a longer payment period. I can pay $___ per month, and would spread the payments over 12 months instead of 3 months.”
“Can we agree to an interest-free payment plan?”
“Please send me monthly statements showing my payments and remaining account balance.”
“Can I please set up an interest-free payment plan?”
“Please send me written confirmation about this payment plan.”
*If you are able to pay some - but not all - of your bill per month, make sure to get a payment plan in writing to avoid having the provider send your account to collections.