FOR CONSUMERS WITH HEALTH INSURANCE COVERAGE
Step One
Understand your health insurance plan
- Your health insurance plan can be a resource for information about healthcare prices.
- Contact your health insurance plan in case of elective surgery cases or prior healthcare service scheduling and inquire information regarding your cost-sharing impact.
- Get the specifics of your health plan coverage, including your deductible, copayment, and coinsurance. This will determine how much of your healthcare costs you will pay, and how much your health plan pays.
- Get information about in-network and out-of-network list of providers inside your insurance plan (see step three)
Step Two
Conversation with your doctor or other healthcare provider
In order to maximize the effectiveness of your price inquiry, whether you decide to use a price transparency tool or calling your health insurance plan, we recommend asking your doctor the following questions:
- What is the exact name of the service, treatment, or procedure?
- What is the CPT code for the service, treatment, or procedure?
- What ICD-9 or ICD-10 codes will be used?
- Will other doctors be involved in my care?
- What tests will I need before a surgery?
- Will other doctors be involved in the surgery or procedure and bill me for their services?
- What medications and follow-up care will I need?
Step Three
Shopping for healthcare services
- Request an estimate or price inquiry: once your doctor provides an answer to your list of questions, you should visit your healthcare provider or health plan’s website and search for available price information. You can request the estimate directly from your provider. However, there is always a chance that the bill you receive will turn out to be higher than the estimate; for this reason, you should keep a copy. The price transparency rule establishes that healthcare providers must provide the most accurate estimate.
- Compare healthcare prices: with publicly health care prices released by different providers, you should compare costs between different hospitals and shop around for the services you need. Consumers should shop services, taking individual cost-sharing circumstances into consideration.
- Confirm network status: when you need care, its important to find out if all of your providers are in your plan’s network. There are times when going outside your network is not in your control, but you should always 1) ask your provider to refer you to other providers inside your network; 2) before shopping a service with a new provider, ask if they participate in your plan; 3) if you choose or is unavoidable to go out-of-network, ask the provider how much you’ll be charged; 4) confirm with your plan to find out how much of the cost will be cover by them, if applicable.
- Ask your health plan about pre-approval: contact your health plan to find out if a pre-approval is needed before you have surgery or receive other healthcare services. This is important, because some services require a pre-approval or pre-authorization from your health plan, or they may not cover your claims.
- Payment and financial opportunities: after receiving a medical bill, you should compare the specifics of the estimate with those on the bill (remember saving a copy). If there differences, you should call your healthcare provider or patient financial services to fin out the reason of such differences, in order make a correction or finding out what options are available to you. Some available options could be 1) asking if you are eligible for a discount; or 2) request an extension or payment plan.
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