How to protect yourself against unexpected medical bills, insurance denials

The U.S. health care system is such a maze to navigate that trying to minimize medical bills is a time-consuming and difficult chore.

It’s the equivalent of a “full-time job to figure out what insurance is going to pay,” said Ann Woloson, executive director of Consumers for Affordable Health Care, a Maine-based patient advocacy group.

But there are ways to help reduce bills and limit costs.

Just as prevention is the best medicine for keeping healthy, planning ahead is one of the best ways to avoid large and unexpected medical bills. Instead of automatically going wherever your primary care physician refers you for screenings and other procedures, for instance, shop around to make sure you won’t be charged more than necessary. Once you go through with a procedure, it’s far more difficult to negotiate a better price.

Costs of surgeries, health screenings and lab tests can vary widely. A simple preventive or screening colonoscopy can cost as little as $254 or as much as $4,290 depending on location, according to the comparemaine.org website.

That website is a good place to start when comparing costs. But the least expensive provider you find for a given service — whether it be delivering a baby, an EKG or a hip replacement — is not necessarily where you want to go, Woloson said. Patients need to ensure they are getting quality care, but also not paying excessive amounts. It’s a tricky balance, she said.

In general, avoid routine screenings and medical services in a hospital, as the extra fees they often tack on could add hundreds, sometimes thousands of dollars, to your bill.

Your insurance carrier also plays a major role in your final cost, so checking with your carrier is also an important step. Your carrier may suggest a different provider than your doctor does.

If you go to a provider outside your network, what you have to pay may be higher even if the total cost is lower, Woloson said.

It’s also important to understand the ins and outs of your health care plan. If you have a high-deductible plan and you’ve already met your deductible for the year, it makes sense to schedule health care services during the same calendar year, rather than waiting until January when your deductible resets. Also, if you know you will need a procedure in an upcoming year, you may want to set aside money in a health savings account. Doing so lets you put untaxed income aside to pay for health care services, effectively using the tax break to lower your costs. Contributions to a health savings account are also tax-deductible.

If you get a bill that doesn’t make sense or is higher than expected, the first step is to ask for an itemized breakdown or explanation.

If you are still being charged more than you believe is fair, you can appeal. But that is difficult because your negotiating power as an individual is limited.

To begin an appeal of an insurance claim denial, follow the directions on your insurance forms.

If you ultimately find that a procedure or service isn’t covered, your health care provider may be willing to give you a discount as high as 25 percent, and may also give you a discount if you pay your bill promptly in full. You should ask for discounts whenever possible, Woloson said, as often a provider will agree to one to get a bill paid sooner.

For free assistance on a medical bill, call the Consumers for Affordable Health Care helpline at 800-965-7476 on any weekday from 8:30 a.m. to 4:30 p.m.

If your appeals to your insurance company or health care providers fail, you can also file a complaint with the Maine Bureau of Insurance.

Some disputes can also be taken to court, but it’s a good idea to consult an attorney before initiating legal action.