Here is the link to earlier and later posts in this series
In case you are confused, the topic of this post is Insurance, Medicare and all the ways our medical bills get paid. How do you navigate all those topics? It can definitely be confusing. I’ll give you some basic terms. Ask if there are others that are unfamiliar to you. You can always google the rest.
I am not presenting this as an expert on all things insurance, social security, medicare, etc. I am simply trying to help you, as a caregiver, get a bird’s eye view on the medical care system so you can figure out the parts of it you need to navigate and understand where you need help. It can be like trying to go through the door marked “nursing” when the help you need is “medicare.” Does that make sense?
If we caregivers are going to navigate this huge system, we need to know where to find the category we need help for in the right place so we know who to talk to with our questions. This is even more true with all the telephone trees that exist where we have to push 1 for one category, 2 for another, etc.
What is the first thing you do when you present for medical care?
The first thing you are asked for in the ER, doctor’s office, hospital or any place you have a test or procedure done, is to present your medicare/insurance cards and photo ID. Why? Because they want to get paid. Always make sure you have those cards with you when you head out for any kind of medical treatment. They are a must!
Today’s topic falls under the big category of “How do the medical bills get paid?” for almost everything except medications. In a sense, this comes first. You make this decision before your loved one is sick. That is what makes it difficult.
- How do you decide which insurance plan to choose?
- How much money do you spend?
- What are your needs? It’s a hard decision, but not as hard as it once was when there were penalties for certain health conditions. I think there still are some limits, for example if you have just been diagnosed recently with cancer, you may not be able to make big changes in your medical plan. But here goes. Pay attention to the date this is written. These things can change quickly and vary from state to state. I live in the state of Alabama.
What plans are available?
Plans generally fall into these categories:
1. Self-pay-This includes uninsured as well as those in plans that share the cost among the members. With most insurance plans, the company and hospital have an agreement to lower the cost of everything because the hospital knows they will get their money. With these plans, the cost is not lowered. You owe the full amount and must pay everything that is charged. There is usually not an agreed on co-pay so you must pay more money up front for treatment. (Of course, even then, you can talk to billing and make arrangements.) You need to realize that almost no one pays the full amount that is billed. The hospital would rather have you pay something, even a lower percentage of the bill, and call it paid, then to have it defaulted on. If you don’t have regular insurance, always ask what can be worked out. You often pay a fee to be a member of these groups, but there is no guarantee they will pay any of your bills. They often advertise as being the “christian” form of insurance. It can be a bit deceptive. Many people I have known in these plans function as if they have no insurance. They don’t go to the doctor unless it is absolutely necessary. Others in the plan promise to pray for them and help them with their bills. It often happens. You just need to know what you are getting into. Examples of this kind of “insurance” are Samaritan Ministries, Medi-share are just two. Each of these have different plans to offer as well.
2. Medicare-You must be a certain age to qualify. Medicare dictates what treatment will be paid for with certain diagnoses. Part of being a good doctor is also coding the charges right so Medicare will pay them. If Medicare won’t pay for something, it can often have a ripple effect in that the supplemental insurance may not pay for it either, so it is important to be aware of what happened on a non-payment and why. Call the appropriate place if a charge is refused. It could be something as simple as a wrong code. That is easy to resolve…or it can be once you talk to the Doctor’s office. But it may be that there is another problem. Talk to the place the bill came from to find out what the problem is so you can sort it out. Medicare has A and B options. Many people choose both. Plan A covers inpatient hospital stays, skilled nursing care, hospice care, and limited home health-care services. Plan B covers doctor office visits, preventive services, many immunizations, mental health and alcohol rehab care, chemo, physical therapy, diabetes supplies and care, and durable medical equipment. Now you see why people tend to participate in both plans?
3. Medicare Insurance supplements-These are great for filling the gaps between what medicare pays and what you pay out of pocket. Depending on which plan you choose, you can go from $0 deductibles to deductibles that are either % based or flat fee based, for office visits, procedures, etc. There are a variety of options available. You can make changes but only once a year in November/December.
4. Medicare Advantage plans-These tend to be less costly. They can be wonderful or not. There are some things you need to watch for with Advantage plans, you have to turn in your Medicare card in exchange for this card. The reason is because Advantage plans don’t offer all the same coverage as Medicare plans. This is why it can be a problem. Some plans lessen the number of Physical Therapy visits they offer, for example. You need to compare to regular medicare coverage and your Advantage coverage. Some plans are great, others are not. While you are healthy, that isn’t a big problem. But if you have a stroke in the middle of the year, it can be a huge problem! Yes, they often add coverage for vision and/or dental that don’t come with medicare. But you want to check to see if your doctor is on the list and if the coverage is worth what you might be giving up. Some states are better than others in terms of their Advantage plans. Just pay attention to any Advantage plan you sign up for to see what Medicare coverage it takes away in order to give you something else you want, like an exercise plan or whatever. It may be a great benefit, it may not be.
5. Straight insurance-this is for those who aren’t in Medicare yet. Many plans are available. You need to compare and see what works best for your budget and your needs.
6. Medicaid-for those who qualify due to low income or excessive medical expenses for a family member. (often preemies, especially those with additional chronic health issues are put on medicaid. this also happens for people who have excessively high medical problems such as a dialysis patient or a patient who has a transplant, in addition to those who qualify directly because of income.) Often, you have limited choices due to the doctors willing to deal with Medicaid and all their paperwork. Sometimes, your doctor will agree to deal with medicaid…but not always.
This is general, but hopefully will be helpful in understanding a bit about how to pay the medical bills. There are many more details available online.
Some tips when having problems understanding a bill or having a difference of opinion regarding payment or coverage
- We don’t help ourselves when we use abusive language toward the person who is trying to help us sort out the problem. We may not like what they are telling us. (i.e.that test won’t be paid for.) Sometimes part of the problem is that we don’t understand the issue. By that I do not mean we don’t understand math. (I give this warning as someone who worked hard and was on the receiving end of too many abusive statements from people who were simply mad about something that had nothing to do with what I had to tell them.) It is not kind or loving or patient. Yes, this is a two-way problem, but we only have control over our side of it. Listening carefully helps a lot I have learned. Yes, it is difficult. Absolutely!
- There are way too many working parts involved than simply math when it comes to these bills. It is also good to remember that the person you are talking to did not set up the policies. They only have to carry them out. If you find you are having trouble communicating with the person/understanding them and you feel it is a mutual problem where you can’t seem to communicate well, you can ask to speak to his/her manager or supervisor. Asking calmly and talking calmly helps. You may need to take slow, deep breaths on occasion. If so, do it.
- Don’t make it a personal thing. Just assume you need a different person with a different perspective to talk to if the communication breaks down. Try to have an attitude that you want to learn more about how the system works so you will understand the way the bill works. Hopefully, that is your mind set. Yes, there are plenty of people that are lazy or even dumb. But there are also a lot of hardworking people in healthcare. Don’t assume they don’t know what they are talking about. They may just be coming at the answer from a different perspective than you are. Take a few minutes to listen to them as they try to help you with your problem.
- Particularly, if you are a Christian, you want to have a genuinely humble attitude toward the people with whom you must interact. From a practical standpoint, it will not help you not to be abusive with people you have to deal with. In fact, it can come back to bite you. One woman in a caregiver group I’m in, got mad at someone at the pharmacy she has to deal with and told her to “Go f— herself.” Yes, she was frustrated. Yes, she had some good reasons for it. But in the end, she was banned from the pharmacy because of her abusive language toward the employee. That can also happen in some doctor’s offices too. More and more, people are weary of dealing with that kind of thing. You don’t want to find out the hard way that you overstepped. Beside the fact that the language was abusive, there are practical reasons for behaving in a kinder way. Many of these offices are constantly dealing with phone calls all day long. If they have someone who is consistently abusive, they are likely to cut you off. They just don’t need it in these days of more and more abuse and abusive language going on.
- There is no question that it is very difficult to be a caregiver. The frustrations are many. But when you have to deal with disagreements on the phone, be sure you are in the right frame of mind when you make your call. Pause before responding to comments that are irritating or that your perceive as demeaning or patronizing. If you don’t, in the end, you may find yourself with more problems to deal with. (see #4) When you respond reasonably or more than reasonably when working through difficult issues on the phone, you stand out.
- There is nothing wrong, mean, or even selfish about making justified complaints for bad or incompetent service or care. It protects the next person from the problems you had. Just make sure you do it in a factual way rather than a way that is personal and tries to judge motives. Let the facts decide motives. Ultimately, we don’t know a person’s motives. Are they lazy or distracted? Are they intentionally rude or feeling stressed to move on to the next call? We don’t truly know the answer. Their supervisor has a better idea. They can sort it all out.
Do you want to be remembered by people who have to deal with you as the person who is rude and difficult to deal with? Or as the kind person who is reasonable and is willing to work through disagreements? I know which one I want to be. I have failed plenty of times,..and had to apologize, but I know what kind of person I want to be and which one represents Jesus better. If you are known to be reasonable most of the time, your complaints will be taken seriously when you must make them.
What if I can’t pay my bill?
Once you get your bill after it has filtered down through different layers of insurance, etc. and you realize you can’t pay the bill, I’m told the best thing to do is call the hospital/doctor’s/insurance company’s office or wherever the bill is coming from. First, you want to be sure it is the final bill. Second, you want to find out how to work out a way to get it paid since you know you can’t pay it. They will work with you on finding a plan, often they will discount the bill, depending on the size of the bill. ‘The important thing to realize is that you need to be on top of things and get in touch with them right away rather than waiting for them and allowing the bill to go to the collection agency. That is not a good thing at all! Then it is out of their hands. Make payment arrangements before the bill goes to a collection agency for best results!
Let no corrupting talk come out of your mouths, but only such as is good for building up,
as fits the occasion, that it may give grace to those who hear.
And do not grieve the Holy Spirit of God, by whom you were sealed for the day of redemption.
Let all bitterness and wrath and anger and clamor and slander be put away from you, along with all malice.
Be kind to one another, tenderhearted, forgiving one another, as God in Christ forgave you.
Ephesians 4:29-32 ESV