The Informed Patient
Know Where Your Health Insurance Stands to Avoid Medical Bill Shock
We’ve all heard it a million times: when in doubt, ask — especially when it’s a question of health. Yet we live in a world of rapidly rising health care costs and constantly changing insurance policies: we often don’t know how much treatments cost, what’s covered by insurance, and how much health care we can a ord. According to Wilson Davenport, SGS of Davenport and Associates (an employee bene ts agency out of McAllen), and Charles Mallon, CFO at Rio Grande Regional Hospital, many people play a game of assumption with their personal policies that leads to outrage at billing processes. However, we cannot a ord to be ignorant about our health; from both the nancial and medical perspective, it’s important to be an informed patient. “I would encourage anyone to research how they fund their health,” Mallon said.
Every Case is Different
Whether you are insured or uninsured, there are certain costs associated with each procedure and it is normal to receive not just a single bill from the hospital, but many bills from an assortment of health care professionals. For example, although patients may argue that they weren’t “seen” by a radiologist during a particular hospital visit, they were performing their service behind the scenes as part of the patient’s treatment, and their charge is valid.
“Health care billing is extremely complicated. Even people who are in the eld need to have a consistently refreshed education on the billing process and stay current with policies,” Mallon said. “Our people are having to constantly stay on top of the rules and regulations, so it’s understandable that patients are going to have issues.”
He says one of the biggest misconceptions he sees is that patients get a bill with a very high number, and think they are expected to pay it all in full. “ ere are many legal and contractual reasons that the charges are so high; it confuses patients, or makes them upset or angry,” he said. “In the case of insured patients, the total in-network charges will be contractually reduced to an amount negotiated with your insurance company. For uninsured patients, they will be asked to pay more out of pocket, but they also qualify for signi cant discounts. e di erence approximates the amount the insurance company would have paid the provider.”
Sable Moya is a McAllen resident who is all too familiar with the di erence having insurance can make. She became pregnant while uninsured,so her baby’s care and delivery at McAllen Medical Center were covered by Medicaid, but her subsequent complications were not. “After the C-section my blood pressure went up, so I had to stay for a few days,” she said, remembering that when it was nally low enough for them to be released, her new son Luke had also just been cleared from the NICU. “On the way home I waited in the car while my husband, Adam, went into a gas station. When he got back to the car, I was having a stroke.” He immediately rushed her back to the hospital because she couldn’t speak or move her right side at all. “I had a seizure while Adam was trying to check us in,” said Moya. “ ey did bedside surgery to drain the blood clot and I was put in a medically induced coma for two weeks. en I was transferred to Houston, where I was in the hospital for two months, then two months in a neuro- rehab facility.”
Moya says that they were able to get insured before the transfer to Houston thanks to the A ordable Care Act. “Because of Obamacare, my life was probably saved,” said Moya. “We saw a bill that said the neurological rehab center was $1,200 a day, but thankfully that was completely covered. I was there for two months, so you can imagine what our debt would be if it wasn’t.”ree years later, Luke is doing well and Moya’s health is fully recovered, but it’s not the same case for the family’s nances. She worries because despite being aware of the importance of having insurance, rates are going up and she is not currently covered. “Adam makes just enough for us to not qualify for Medicaid but we can’t a ord insurance on our own right now,” says Moya. “In case something massive like this happens, it’s so important. But what can we do?”
Uninsured but not Alone Mallon says that they see uninsured patients coming into the Emergency Department, where they are stabilized as required by the federal Emergency Medical Treatment and Labor Act (EMTALA), regardless of their insurance status or ability to pay. “It doesn’t mean they get care for free, but the physician will see them and assess them, then discharge them with instructions to seek a clinic. If they’re unable to pay at that time we’ll send a bill.”
Sable Moya says that the bills incurred in those two weeks before she got insured had to be paid out of pocket, but they were fortunate that her husband is a local musician who was able to throw fundraiser shows to help with the cost. “He ended up raising thousands, but it all went to my bills, every penny,” she said. “We’re so grateful. If the community hadn’t helped us, we’d be in such tremendous debt.” Online, it’s not uncommon to see individuals creating GoFundMe or other crowdfunding accounts to cover their medical bills. Rio Grande Regional Hospital also has a charity program that helps the uninsured, but operates on a case-by-case basis.
Uninsured direct admission patients not having an emergency (those sent to the hospital directly by their primary care provider for any reason) do not fall under EMTALA and hospitals do not have to admit them if they are unable to pay. Mallon explains that complications may arise that may impact the cost of care for these patients. ey are given the best estimate prior to the procedure, but no two cases are exactly alike. e initial estimate is just that — an estimate, not a guarantee.
The Value of Knowing
If you do have the opportunity to get insurance, it’s important to understand it to make the best choices for your health and nances. Your doctor and your insurer are there to provide answers which should bring comfort and resolution. Like all hospitals, Rio Grande Regional Hospital has employees who are dedicated solely to explaining billing and helping patients understand the nancial aspect of the treatment they received. However, it is helpful when the patient can meet them halfway with the information.
“If we can issue a clean bill with all the proper data and information, we can process a clean claim and hopefully the patient’s outcome is also a clean bill of health,” Mallon said. Even though it can be confusing, it’s important for insured patients to sit down with their HR representative or insurance agent to form a complete understanding of their part of the responsibility — ideally before they need to use their insurance. Adriana Morales, Director of Community & Public Relations at Rio Grande Regional Hospital, says it’s our individual responsibility as consumers to be aware of what we’re purchasing and what’s covered. “Most insurance plans often include preventive care,” she said. “Being informed and taking advantage of those bene ts means taking a proactive approach to your health.”
At the time of open enrollment when health insurance is o ered, individuals have to decide between a plan that costs less per month, but has higher deductibles or copays when you use the services — or one that takes more out of your paychecks, but will typically drive down those same costs when used. “Do people really understand that? Sometimes,” Mallon said, explaining that the best choice comes down to the consumer knowing themselves and their family’s health, ages, and activity level. ese all factor into whether the family will likely meet a high deductible. For example, a plan with a low monthly cost may have a deductible requiring thousands to be spent on health care before the insurance company reimburses the client. “Always try to have a sense of where you are with your deductible,” he said. “If you meet your deductible early in the year, your patient responsibility will be greatly reduced the remainder of the year. Some people never meet it for the entire year.”
Along with information about deductibles and copays, individuals should be aware of the network of physicians and providers they can visit without problem. When employers put a plan together, they work with the insurance company which contracts with certain doctors or hospitals. Patients who are out of network don’t get the contractual rate, and it will cost the insurance company more to pay for that claim — which, of course, is passed down to the individual. Davenport says that policyholders are generally unaware that not all procedures or providers are covered or part of their network. “Prior to a non-emergency procedure, get authorization from the insurance carrier and make sure the health care provider is in-network to avoid further out-of-pocket cost,” he said. “Research the doctors, facilities, pharmacies — whatever medical care you need. Education is key.”
When you go to the garage to get your car worked on, you skeptically wonder if the mechanic is trying to pull a fast one when they say that the problem lies in your “ ux capacitor,” which will cost you $1,200. (No matter what, it’s always $1,200, isn’t it?) Nobody wants to spend that kind of money on a repair, so we almost always ask questions. You can and you should! ere may be alternatives that can save you a lot of money — and the same is true, in many cases, with health care.
“Most patients do what the doctor tells them and go where the doctor tells them to go, but patients have a choice and they should ask questions,” Mallon said. Have a list of questions to ask before you agree to a costly procedure. “Patients can say no to too many services attached to a procedure, depending on the situation,” Mallon said. As a consumer, you need to be aware of your ability to waive some things or request more a ordable alternatives, such as generic drugs.
Davenport adds that the insured can deny any recommended service/procedure from a doctor as well as deny services from any particular doctor. “ ey can request the doctor, facility or lab of their choice to get a particular test or procedure completed,” Davenport said. However, individuals must be very informed about their bene ts to see how making these choices might a ect their out-of-pocket cost. e same applies to ambulances: in a non-life-threatening situation, individuals can request that EMS take them to a doctor or hospital that’s in their network as opposed to the closest one.
Sable Moya and her husband can also attest to the patient’s involvement in the decision-making process. While the local hospital suggested a wait-and-see approach to her recovery, she knew that the rst six months after a stroke are crucial for recovery. Moya wanted to make as much progress as possible while she could, which would take therapy. “I went from sitting in a wheelchair, unable to move, to walking and talking and taking care of my son within a number of months. It made a huge di erence,” she said. “If we had said ‘I guess the doctors know best,’ I would probably be in a nursing home right now.”
Education is certainly key when it comes to avoiding expensive and dangerous missteps with our health — that’s what makes the question-asking process imperative. “With all the changes in health care and insurance for the past several years, be in control of your medical care and understand your bene ts,” Davenport said. Armed with information, residents of the Rio Grande Valley will be empowered to take charge of their health.