Dealing with Hospital Costs If You Have Insurance

If you have insurance in any form—HMO, Medicaid, Medicare, indemnity, and so on—you must understand that the insurance company is likely not going to cover everything the hospital bills you for. The first place to start, therefore, is to look at your policy to determine what is covered and what is not. These are the questions you need answered:

• If the insurance is managed care insurance, is the hospital part of the plan’s network? Network hospitals have negotiated rates with the plan and you will be covered for a lot of the hospital’s charges based on your policy. If the hospital is not in the network, you will have to pay for all or a big portion of the charges, unless the visit was due to an emergency. With Medicare and Medicaid, the hospital just has to be certified as a Medicare or Medicaid provider for you to get the benefits (nearly all hospitals are). With indemnity insurance, you can go to any hospital of your choosing but remember the plan will only pay a portion of the charges that it determines to be usual and customary. Also remember the caps on your insurance. If you exceed that cap, you are responsible for 100 percent of the charges.
• What aspects of the “hotel” and “medical” charges are covered? Your insurance plan does not give you free reign to ask for five-star services. If your plan pays only for a shared room and you ask for a private room, you will be charged for the difference. This applies to
  other services that you request outside the customary services, for example, asking for a special diet.

In looking at the “medical” aspect of your bill, be sure that you follow your plan’s protocol. In an HMO plan, for example, you should be admitted to a network hospital by your PCP or a specialist to whom you were referred by your PCP. While in the hospital, be sure that consultations are done with your PCP’s approval and/or the doctors are all affiliated with the hospital and are in the plan’s network. While this might sound cumbersome and difficult to handle especially if you are very sick, it might mean the difference between coming out financially unscathed and having to file for bankruptcy. If you can’t handle it, find a friend or family member to help you with this. Remember, procedures that physicians perform account for the bulk of hospital charges, so handle this aspect with all seriousness.