Consumer Tips

 

READ YOUR INSURANCE MATERIALS CAREFULLY

  • Your insurance plan may only cover in network doctors. These doctors are listed in a "provider directory." When you use a doctor who is not on this list, you are going out of network.
  • If your insurance plan does not cover out-of-network care, you will have to pay the whole medical bill yourself.
  • If your plan does cover out-of-network care, you will still have to pay part of the bill yourself. You may have to pay more for out-of-network care.
  • You may have to get your insurer's approval before you go out-of-network or before you have certain kinds of medical procedures.
  • Your insurer may cover out-of-network care if you had an emergency, or if it has no qualified doctor in its network.

ASK QUESTIONS

  • Ask whether your doctor is in network.
  • If your doctor is out of network, and you want to stay in network, ask if your doctor has a partner in network, or can recommend another doctor who is in network.
  • If you are planning to go to the hospital, ask if your doctor will be in network. Even if the hospital is in network, your doctor may be out of network, which may cost you more money.
  • Get help understanding your insurance plan and your costs. Ask your doctor's billing coordinator, your employer's benefits coordinator, a family member or friend.
  • Take notes of your conversations with your insurer and keep complete records of correspondence and bills.

EVALUATE THE COST AHEAD OF TIME

  • If you are thinking about going out of network, ask whether your doctor can provide an estimate, and ask whether your insurer can tell you what it expects to pay.
  • Some insurers will give you this information ahead of time if the doctor can give you enough information. The insurer may ask you for the billing codes, known as "CPT Codes." Ask your doctor for these ahead of time. Ask for this information in writing if possible.
  • Your insurance plan may require you to pay a deductible before it covers any out-of-network costs. If you have not met the deductible, you may have to pay the whole medical bill yourself.
  • Your insurance plan may require you to pay coinsurance for out-of-network care. For example, if your coinsurance is 20 percent, this means you have to pay 20 percent of the amount covered by the insurer. For example, suppose your coinsurance is 20 percent, and the bill from an out-of-network doctor is $100. If your insurer covers the full bill of $100, it will only pay you $80, because you are responsible for 20 percent of the bill ($20). If your insurer thinks your doctor should have billed you only $80 (for example, on the grounds that $80 was the usual and customary rate), then it will pay you 80 percent of $80, which is $64. You will be responsible for the balance of the bill, which is $36.

WHAT TO DO IF YOUR INSURER PAYS LESS THAN YOU THINK IS FAIR

  • You have the right to appeal. Read your insurance materials and the notice from your insurer, called an explanation of benefits. It will explain how to appeal.
  • If you can't pay, try to negotiate the bill with your doctor, or see if the doctor will agree to a payment plan.
  • Be wary of credit card offers to cover medical bills. The interest rate may be very high or may start low and then change to a higher rate without you noticing.
  • Your doctor's billing coordinator or your employer's benefit manager may assist you in filing claims forms and appeals and advocating with the insurance company.
  • If you live or work in New York, the Attorney General's Office may be able to assist you by advocating for you with your insurer. Click here to file a complaint.
  • If you do not live or work in New York, contact your local Attorney General's Office or Department of Insurance for assistance.
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