It’s no secret that the United States offers some of the best healthcare in the world, but it comes with a hefty price tag. Thankfully, health insurance helps carry the vast majority of this burden in most cases, but there are still times when members may receive bills that were not covered by their plan. This is why we’ve put together an article outlining why your members may be receiving medical bills, what to do about them, and how to help your members avoid outstanding invoices in the future.
There are several reasons why members may be receiving bills from a recent visit to the doctor. Here are some examples:
The bills were never sent to the insurance company - This can occur when members don’t show their insurance ID card at their appointment, or by an oversight on the provider’s end.
The resolution: In these situations, the member needs to contact the hospital or clinic directly and ask that they submit an itemized bill to their insurance. It’s important that the participant has their insurance ID card handy when placing the call as the provider will likely need to ask a few questions about the information listed on the card.
The insurance company needs additional information - Bills can sometimes make their way to the insurance company properly, but additional information, such as a claim form or medical records, is needed to resolve the claim. In these situations, providers may choose to send a bill to the member while things are sorted on the insurance carrier’s side.
The resolution: Whenever a bill is received, a member’s first step should be to contact the insurance company to see why the bill has yet to be paid. The carrier will be able to outline the rationale behind any delays and clearly explain what documents may be pending to finalize the claim.
The visit isn’t eligible for coverage on the insurance plan - If the member sought treatment for something that the plan doesn’t cover, the insurance company would deny the bill, and the member becomes responsible for paying the outstanding balance. At this point, the provider will begin to send bills to the member.
The resolution: Members have the right to appeal any denied bills directly with the insurance company. If the member chooses not to appeal, they can try to negotiate the balance directly with the provider. The provider has the ability to lower the balance or even write it off completely, but this is at their discretion. More information on this topic is listed in the next section.
The policy or benefit maximum for the insurance plan is exhausted - Each insurance plan as a whole offers up to a specific dollar amount in coverage and sometimes individual benefits will also have a cap. If a member were to have a severe accident or illness and their medical bills surpass the policy or benefit maximum, any overage would become the member’s responsibility. The provider would send these bills to the member directly.
The resolution: The member will need to work directly with the provider in the hopes they will lower or write off the remaining balance.
Simply because a medical bill arrives in a member’s physical or virtual mailbox, it doesn’t necessarily mean that it is the participant’s responsibility to pay the outstanding balance. As a general rule of thumb, whenever a bill is received, the member should call the insurance company first to ensure that the bill is on file, and find out if anything is needed for the bill to be processed. Members can also check their online claims tracking portal to confirm if anything further is needed to get their claims processed.
It’s natural for members to receive a bill and assume that they are responsible for paying the outstanding balance, but this is far from being true in many situations.
Thankfully, providers generally will work with members to find a reasonable way of helping to eliminate debt, even if that means accepting less than what was originally billed. Here are the two steps that members need to take if they are ultimately responsible for the bill, but are unable or unwilling to pay the balance.
Action Item #1: Have the Member Call the Provider and Request that the Bill is Reduced
Encouraging the member to call the provider and request the bill is reduced is crucial. This shows providers that the member is aware of the balance and wants to do what they can to eliminate it. Sometimes a simple call and request to the hospital or doctor’s office will be sufficient to have the bills lowered; oftentimes providers will accept a lump-sum payment of a fraction of the overall bill. This allows them to close the account and keeps the member from having to pay the larger balance.
Due to HIPPA laws in the United States, only the member will be able to call the provider and negotiate their debts. That being said, your account manager would be happy to join the member on the call, if he or she would like. Having a seasoned negotiator and someone who knows the ins and outs of the collections process can help make the call that much more successful.
Action Item #2: Encourage the Member to Write a Hardship Letter to the Provider
Other times, providers will need a request in writing to lower or write off bills, and this is where the Letter of Hardship comes to play. This letter is the member’s opportunity to explain why they are unable to pay the bill and any other details that will help the provider see the situation from the member’s perspective. This letter needs to be as comprehensive as possible and help encourage sympathy and compassion for the member.
*Please contact your account manager, and they will be happy to assist with this process.
Once the letter is written, send it and any accompanying paperwork to your account manager. They will review the letter on the member’s behalf and offer suggestions for improvement. Once the letter is finalized, the member should send it to the provider for their decision. Providers generally take 30 business days or so to review these requests, but it’s a good idea for members to contact the provider immediately after sending the Letter of Hardship to ensure it was received and to confirm when a decision will likely be made.
Now that you’re armed with information on how to help your members manage unpaid medical bills, here are some tips to help ensure the bills don’t arise in the first place.
Whenever possible, members need to use in-network providers. Seeking treatment from doctors and hospitals that are contracted to both accept a member’s insurance plan and then offer deep discounts for services will help lower medical bills dramatically. The claims process will be more streamlined this way since the provider will bill directly rather than expecting payment up front and the amount of the bill as a whole will be greatly reduced thanks to the PPO’s discount. It’s a win, win!
Encourage your members to contact the insurance company before visiting the doctor. Connecting with the insurance company by phone or email prior to visiting the doctor can save your members not only time but also eliminate confusion and ultimately help save them from incurring ineligible medical bills. For example, if a member were to call the insurance company and ask how much a visit would cost for a yearly check-up, the carrier should let the member know that that kind of visit isn’t covered and the entire bill would need to be paid out of pocket [this is true for most plans but not all]. This would prompt the member to know in advance that their visit wouldn’t be covered, so they can adequately decide if they’d still like to schedule the appointment, knowing that they’ll be responsible for the bill in its entirety.
It’s also important to recognize that surgeries and other high-dollar services need to be pre-certified with the insurance company in advance. If members are in the habit of calling or emailing the insurance company before seeking treatment, this will also ensure that pre-certifications are taken care of, resulting in the carrier paying as much of the overall bill as possible.
Ask that members familiarize themselves with the Student Zone and policy brochure. When members are initially enrolled into the insurance plan they are given a copy of the policy brochure and a link to their online insurance portal, called the Student Zone. Both of these resources include helpful information about how to file claims and the importance of doing so. The online Zone specifically is a fantastic and comprehensive resource that offers an in-depth look at which forms are needed for any given claim and also includes a link directly to the online claim portal. A link to the Student Zone can be found on any member’s ID card and additional copies of the plan brochure can be downloaded from the Zone.
Remind members to periodically follow up on their claims. Oftentimes, claims aren’t processed and paid because documentation is missing on the member’s end. It’s a good idea to encourage members to fill out a claim form for every new condition. This form will take less than 5 minutes to complete and having it on file means one less thing that may delay the claim being processed. Each insurance company has an email, phone number, and an online claim portal that will allow members to quickly check to see if anything is needed to get their claims resolved. If members are confused about any pending documents, translators are available to help.
If you have any questions on how to manage unpaid medical bills or craft a Letter of Hardship, don’t hesitate to reach out to your account manager for assistance. They are regularly assisting with making sure claims are processed correctly and can help you and your members navigate through each of the points listed above. And don’t forget: simply because an invoice is received doesn’t necessarily mean that the member is responsible for the balance.
For future or current participants who are insured on our plans, you can view all the details about your plan through your Student Zone. You can find this information in your welcome email and insurance ID card. If you cannot find this, please contact us.Contact Us