How to Research Health Care Prices

It’s long been hard for health-care consumers to learn how much doctor visits or hospital stays will cost them. That’s now beginning to change, as a growing array of Web sites try to lift the veil on pricing.

The online resources come from insurers, government agencies, Internet companies and medical-care providers. The sites aren’t perfect: Unlike online retailers that sell products such as televisions, the health sites can’t typically give exact prices for medical procedures and services. Still, consumers can get a rough idea of typical costs in their area, and that can help them choose doctors and hospitals, budget for medical costs and sort out disputed bills.

The mystery surrounding health-care pricing stems partly from the fact that hospitals and other providers generally don’t publicize how much they’re paid for services, which varies depending on who’s footing the bill. Insurers, which often contract to receive lower prices for their customers, also have traditionally not revealed these negotiated amounts.

But soaring health-care costs have made consumers more conscious of price. Even consumers with health insurance increasingly find that they have a stake in the cost of their care because they’re paying a far bigger share out of their own pockets. For instance, more than half of workers pay a percentage of the price of outpatient surgery and hospital admissions, rather than just flat copayments.

Consumers also can’t rely on their health plan’s contracts to always deliver the lowest price, because the same insurer might pay widely varying amounts to different care providers. In Maine, one insurer’s preferred-provider organization has paid between $559 and $4,526 for a colonoscopy in a given year, including the portion due from patients, according to data compiled by the state.

To find useful information, you’ll generally have to do some digging and check multiple sites. Each takes a different approach, and they can be confusing. Several sites, including some offered by hospital associations, use listed charges—the “sticker prices” that are typically much more than insurers pay. Other sites focus on the rates paid by private insurance plans or Medicare. It’s also often unclear whether a Web site’s estimate represents the full cost of a procedure, including, for instance, anesthesiology fees.

Consumers also should pay attention to the quality of care, by seeking personal references or checking Web sites such as Medicare’s HospitalCompare.hhs.gov and LeapfrogGroup.org.

If you’re insured, a good place to start your research is your health plan. The big national insurers, including WellPoint, UnitedHealth Group Inc., Humana Inc., Aetna Inc. and Cigna Corp., offer pricing tools to their customers, which the companies are continuing to enhance. Still, insurance company data don’t include all health-care providers or procedures, and they typically only give price ranges. Also, of course, you won’t be able to directly access the information if you aren’t a client.

A few states, including New Hampshire, Maine, Oregon and Massachusetts, have started providing pricing information based on databases of insurance claims, which give a detailed picture of costs. Other states, including Utah, Vermont and Tennessee, are building similar databases. And some nonprofits, such as MN Community Measurement in Minnesota, are also offering state-focused pricing information based on insurer data.

Several Internet companies now operate sites that let consumers around the U.S. search for pricing in their area. HealthcareBlueBook.com offers a suggested “fair price” for a service, based on a database of rates paid by private insurers, according to parent company CareOperative LLC.

Changehealthcare.com, a unit of change:healthcare Inc., provides estimates of how much individual providers are paid by insurers, based on claims data from health plans. And NewChoiceHealth.com gives providers’ list prices, which are derived from Medicare data, according to New Choice Health Inc. Another site, OutOfPocket.com, has a search service to help users find online pricing information listed on various sites.

You can also check for prices posted by specific hospitals and doctors. These are still relatively rare, and may represent list charges. But a few hospitals are also revealing roughly what they’re paid by insurers or offering calculators so insured patients can figure their out-of-pocket fees. A site called PriceDoc.com seeks to aggregate listings from doctors.

Medicare data can also be a useful resource, though hard to find in a consumer-friendly format. A few savvy consumers use an American Medical Association Web site to look up what the federal program pays doctors for that type of care, then use that as a starting point in seeking a good price.

Once you’ve done your online financial due diligence, you should discuss prices with medical practices or hospitals before going in for any treatment. If you’re not insured, or going out of your health plan’s network, and want to negotiate, you can start by aiming for the Medicare rate or something close to what commercial insurers pay, though you may not be able to get to that price point. You may get a better deal if you are willing to pay cash up front.

If you have coverage, you should also talk to your insurer about what you will pay out of pocket for any care. Keep in mind that even a relatively simple procedure can cost more if there are complications.

Researching health-care pricing online can also help after you’ve already had a medical procedure, if you want to dispute a bill, negotiate it down, or figure out if you’ve been overcharged.

How to Avoid Surprise Medical Bills

Few things are more unpleasant than getting hit with an unexpected medical bill. But there are steps you can take to avoid at least certain types of surprises.

First, you should check with your insurer and the doctor and hospital before you get treatment. Obviously, this isn’t always possible. And even when you do get a chance to ask, you may find it frustrating and uninformative, since many medical providers and health plans refuse to provide up-front estimates.

Still, a growing number of insurers, hospitals and doctors will try to give you a projection of the cost for planned procedures such as childbirth. For instance, Baptist Health South Florida, a hospital system with headquarters in in Coral Gables, has experts on call 24 hours a day to provide cost projections that include both the fees of the hospital and the doctors who work there. A few hospital operators, including Geisinger Health System, based in Danville, Pa., actually have Web sites that can generate estimated out-of-pocket costs.

After you get treatment, you should ask for an itemized bill and look for procedures that you didn’t actually receive. Since these bills are often tough to decipher, call the hospital. You can also turn to a patient advocate or claims consultant for help, though they will likely charge you for the advice. Among the options are the nonprofit Patient Advocate Foundation. Other organizations and companies can be found at the end of this article.

Still, be warned: often, if you are insured, your itemized bill has no relationship whatsoever to what you or your insurer will actually be paying. Often, this contracted rate isn’t tied to the hospital’s so-called “gross charges,” but instead is based on a daily fee or some other structure.

Here are a couple of common types of unexpected medical charges, and how to steer clear of them:

Balance billing

Before you get any planned treatment, you’ll want to check whether the hospital or doctor you are using is in your insurer’s network, since you will likely pay more if you get out-of-network care (or, in some cases, you can’t use such medical providers at all). But don’t stop there.

You’ll also want to ask detailed questions about the potential role of out-of-network doctors in your treatment. One common type of unexpected medical bill hits consumers when they unwittingly get care from a facility or doctor who doesn’t participate with their insurer. Then, the medical provider “balance bills” you for the difference between your insurer’s payment and the total charge.

Often, this happens with a doctor who doesn’t join the same networks as the hospital where he or she works. So you may confirm that you’re using an in-network hospital and an in-network surgeon, but you may have no idea that the anesthesiologist you are also forced to use is out-of-network, and therefore far more pricey.

Anesthesiologists, radiologists and pathologists are often the most likely to not accept many health plans, but they’re not the only ones. Specialists such as cardiologists who are brought in for consultation can also be problematic, and occasionally neonatal units aren’t in the same networks as the hospitals where they reside. If possible, you can request an in-network provider, or you can seek to work out terms in advance with the doctor and insurer.

You should also watch out for the opposite situation, when your doctor is in the network but she operates at a center that isn’t – leaving you with large so-called “facility charges” that your insurer may not cover. In that case, try to see if your doctor can work at another facility.

After medical treatment, you should expect to have to pay out-of-pocket any co-payment or co-insurance fee, and any deductible that your plan requires. If you get a bill that goes beyond these, start by calling your insurer and the doctor’s office for more information, as well as your employer if your health benefits are from your workplace.

Find out if you are being balance billed by a health-care provider who is in your network and for a service covered by your plan. If so, you probably don’t have to pay. States generally prohibit such charges, which also typically violate your insurer’s contract with the doctor. And Medicare patients are never supposed to be balance-billed.

If the doctor is not in your insurer’s network, there still might be steps you can take. Some states have regulations that may protect you from balance billing in certain situations, most commonly emergencies. Check with your state’s insurance regulator.

Your insurer also may be able to help; companies’ responses to unexpected out-of-network balance bills often depend on the member’s particular benefits package and whether the care was for an emergency or not. In any case, insurers say consumers should call them before writing any checks to the doctors.

Preventive care

Company health plans increasingly are offering to pay the full cost of preventive services such as physicals, colonoscopies and mammograms to help employees stay healthy. But some patients then find they owe money for such screenings, sometimes hundreds or thousands of dollars, because their insurers didn’t consider certain procedures preventive.

This type of billing problem is often tied to the system of codes that doctors use in the claims they send to insurers. Every service performed by a physician is translated into a code. So is the patient’s diagnosis. Based on those codes, insurers automatically send out payments and generate explanations of benefits for consumers. Patients get socked with unforeseen bills when their doctors’ offices don’t use the specific codes that their insurers classify as preventive.

Sometimes, the doctor’s office makes an error or doesn’t know the insurer’s procedures, which vary by company. For instance, an annual preventive-care exam, which a health plan might pay for in full, can mistakenly be described in a claim as a typical doctor visit to deal with a patient’s existing symptoms. That could result in the patient being billed for various charges, including a co-payment or a deductible.

Other times, surprise bills arise when a patient unknowingly received some care the health plan didn’t consider preventive – even if it resulted from a finding made during a screening. For instance, doctors may order more views of suspicious masses they spot as they are doing screening mammograms. This then gets appropriately billed as a diagnostic mammogram, which deals with existing symptoms, rather than a screening, which is for people without any specific signs of risk. For patients, that shift could mean new fees.

It’s best to head off such billing snags before they occur. If you plan a preventive-care doctor visit, call your insurer to find out what is covered. Try to get very specific information, including the actual preventive codes the company accepts. When you make the appointment for your screening, be sure to say exactly what services you are seeking. Speak to someone at the front desk when you come in about what your health plan covers. Briefly talk to your doctor about the nature of the visit.

If you get a bill for a preventive service you thought was free, start by checking the explanation of benefits sent to you by your insurer. Then, call the health plan to learn more about why the work wasn’t fully covered.

You should ask if a senior claims examiner can re-check the claim. The claim was probably processed by computers that may not catch everything. For example, your doctor may have used a proper preventive code for your diagnosis, but not listed it first. The order in which codes appear on a claim can affect whether procedures are covered. Insurers say they can review the order of codes on a claim, and may be able to reclassify the payment. But they can’t add or remove codes.

If the insurer says the health-care provider used the wrong codes, ask the insurance company representative to stay on the line as you speak to the doctor’s office. If that isn’t possible, get the rep to give you a very detailed explanation of the difficulty.

When you call the doctor’s office, ask for clarification but don’t be accusatory. Doctors often refuse to change coding if they feel it accurately represents work they have done, even if the patient didn’t understand what the charges would be. However, physician practice administrators say they will fix errors and may even forgive a regular patient’s payment.

People with workplace health coverage can call their employer’s human-resources officials, who may be able to intervene with the insurer. However, privacy laws may limit what the HR department can do for you.

How to Appeal a Health Insurance Denial

Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to appeal a coverage denial, there are several strategies that can bolster your case.

Some health-coverage problems — such as when your doctor enters a wrong code on a claim form — can be resolved with a phone call. But other issues can be more difficult, because they center on complex medical questions like whether a certain cancer treatment is appropriate for you.

First, figure out what led to the denial of coverage and learn your insurer’s procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can’t be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.

You will need the denial letter. You should also get a copy of your plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Corp. and Aetna Inc., post their medical policies online.

After you gather the facts, set a strategy. You may want to start by seeking help from one of the array of nonprofit and for-profit entities that offer advice. Many states have health insurance consumer advocates. The advocacy group Families USA offers a list of state resources.

Another key resource is the nonprofit Patient Advocate Foundation, which handles health-insurance appeals for free. Other organizations and companies can be found at the following Web sites:
Claims.org
Hospitalbillreview.com
Healthproponent.com
Billadvocates.com
Healthchampion.net
Patientcare4u.com.

Your appeal may hinge on proving that your treatment qualifies for coverage under your plan’s benefits and rules. In that case, you will want to zero in on the plan’s language, and figure out why the procedure you are seeking fits into a category of care that the insurer has promised to pay for.

Many appeals hinge on a different issue: whether a treatment is scientifically proven and medically necessary. Your doctor should be able to write a detailed letter on your behalf. You also may be able to bolster your case by researching the scientific evidence online on sites like pubmed.gov, sponsored by the National Library of Medicine. You are seeking studies that may demonstrate that the treatment you want has worked in cases similar to yours. The strongest evidence comes from large, randomized, controlled trials, but anything published in a reputable medical journal might help. You should show your findings to your doctor, so he or she can explain anything you don’t understand, as well as integrate anything important into his or her letter to the insurer.

You may also want to seek help from researchers who worked on the cutting-edge studies you find – sometimes, these doctors are willing to help a patient with an urgent case. They might even review your medical records and submit a backup letter on your behalf, which can add weight to your own doctor’s views.

Even if your insurer rejects your appeal, you still have other options. If your employer has a self-funded health plan, which might be administered by a private insurer but is backed by the employer, your next step is often to sue in federal court, a tough and expensive proposition.

But if your coverage is with an insurance company, either through your employer or an individual policy, you can opt for your state’s appeals process. Often, these are handled through the state’s insurance regulator, but if not, this agency should at least be able to tell you where to go. Make sure you check with the agency, because the 44 states that offer independent reviews won’t handle all kinds of issues, and each has its own rules. For Medicare beneficiaries, there is a separate, federal appeals-review process that you can learn about at Medicare.gov.

How to Buy an Individual Health Insurance Plan

More Americans are buying their own health insurance, but the process can be tough. There are ways to make sure you understand what you’re buying, and that you get the product that’s best for you.

You may want to start by confirming that you really do need to buy individual insurance. For many people, it’s better to avoid the individual market, since in most states insurers can reject you because of preexisting health conditions.

The Kaiser Family Foundation web site is a good place to start in researching your eligibility for various government programs or, if you are losing coverage because of a layoff, continuing workplace benefits through the federal law known as Cobra. Once Cobra coverage runs out, insurers may be required under federal law to sell you another policy, though there’s no guarantee on the price. But different states implement this rule in different ways.

If you are going to buy your own insurance, start your research with Web sites that explain the basics, such as healthinsuranceinfo.net, sponsored by the Georgetown University Health Policy Institute, and healthcarecoach.com, from the nonprofit National Health Law Program. They will help you understand the concepts and language of health insurance, which aren’t always easy to grasp, and should give you some sense of the questions to ask about any plan. Healthinsurance.org has useful information, but be aware that the site also provides insurance quotes from what it calls “carefully chosen partners who are in the business of selling health insurance.”

Then you can noodle around on Web-based brokerages that sell health insurance, including eHealthInsurance.com, HealthPlanOne.com, HealthInsurance.com and InsureMonkey.com. You can get estimates based on limited anonymous information.

Some consumers choose plans based solely on online research. But without guidance, it can be tough to fully understand the nuances of a plan and how it compares to other options. First, make sure you’re actually buying insurance, not some other product such as a discount card – one key way to tell is by checking with your state regulator that the company selling the product is considered a legitimate insurer. Be very careful about limited products such as temporary insurance, which last for a set period of time, since you may not be able to renew such a plan at the end of that period.

When you examine policies, don’t just look at premiums. Figure in other fees you will face, such as a percentage of the cost of doctor visits. Make sure you understand the policy’s annual out-of-pocket maximum, meaning the most you might have to spend in a year, since certain charges might not count toward the total. Some insurers require you to track your own spending and tell the company when you have reached your maximum, which might be a headache.

Read the fine print about your deductible, which is the amount of money you must lay out before your insurer starts paying. Some policies may have multiple deductibles, including one for each family member. Insurers may also not count certain costs toward the deductible.

Also, watch out for benefit limits, including annual and lifetime maximum payouts. So-called “mini-med” policies that cap their payouts can be dangerous, since you might end up paying bills for thousands of dollars if you have a major illness or surgery. Certain plans pay only a set fee per day of a hospital stay, which could leave you on the hook for thousands of dollars. Drug benefits don’t always include every medication. Some policies exclude maternity coverage, or don’t include care for pre-existing conditions.

And keep in mind that just because something isn’t in the “excluded benefits” section of your plan doesn’t mean it’s actually covered. For instance, insurers typically refuse to cover all treatments they don’t consider “medically necessary.”

Before making a final decision to purchase a policy, closely review the full plan explanation, sometimes called the certificate of coverage or the evidence of coverage, and seek help from the Web brokerage’s agents or other experts if you don’t understand it. Insurers may let you review this this document only after you tentatively choose a plan and are accepted for coverage.

First-time purchasers should strongly consider consulting several independent agents before buying to compare their advice. To find an agent, ask friends or family members for recommendations. You can find agents who specialize in health insurance through the National Association of Health Underwriters. Online brokerages also typically have live agents available to answer questions by phone.

Check with your state regulator that an agent has a valid license and a clean record, and make sure health insurance isn’t a sideline or a new specialty. You want an agent who represents a number of major insurers, rather than just one company. You also may want to ask agents how they’re compensated. Agents get commissions from insurers for each policy they sell, often calculated as a percentage of a customer’s premiums. These can range from around 3% to as high as 20%, according to agents and insurance officials. You want to know if your agent will make more money from selling you a certain plan. Also, commissions can be higher in the first year of a policy, an incentive for unscrupulous agents to “churn” clients, or try to get them to switch policies.

An agent should learn your financial limits and any health issues. One good sign is if an agent asks about your eligibility for government programs or the Cobra subsidy. These make no money for the agent but may be the best options for you.

An agent should help guide you toward the insurer most likely to accept you. Keep in mind that if you are rejected by one carrier, you will probably have to disclose that in future applications. An agent also should help you fill out the application. But make sure that you know what’s in the application and that it is accurate. If you make mistakes, you may give the insurer an opening to rescind your policy later.

Finally, you should expect your agent to continue advising and helping you even after you purchase a policy. If you aren’t satisfied, you can change agents. In many cases, you can also redirect the flow of commissions tied to your plan to your new agent by informing the health insurer that you want to designate a new agent of record.

How to Keep Health Insurance When You’re Laid Off

Getting laid off is never easy, and one of the toughest aspects can be losing the health benefits that go along with being employed. There are several options available to keep yourself and your family insured, each with its own advantages and pitfalls.

Keeping employer coverage. The best choice, if it is available, is to seek coverage from a family member’s employer. Even if it isn’t open-enrollment season, when employees make their coverage selections for the following year, you may have the right to join a spouse’s plan if you act within 30 days after you lose your workplace coverage.

You can also stick with your own employer-sponsored plan under Cobra, the 1986 Consolidated Omnibus Budget Reconciliation Act. The protection generally lasts up to 18 months, and you must opt for Cobra within 60 days of losing your job or of receiving formal notification that you are eligible for the program, whichever is later. The statute includes only companies with 20 or more employees that are continuing to offer a health plan. But some states have their own versions of Cobra that may include employees of smaller companies or cover a different time span.

If you choose to take Cobra coverage, you must keep the health plan you had before you lost your job. After you are in Cobra, you can switch plans — if you should want lower-cost coverage, for instance — when the company’s active employees go through open enrollment. If you think you may be at risk of losing your job, it may be worth selecting a lower-premium plan while you’re still working for the company.

The advantages of Cobra are clear: you know the plan, which is often rich, and your preexisting health conditions don’t disqualify you from keeping the coverage. Cobra’s biggest downside is the cost. Active employees generally pay roughly 25% of their total health-insurance premiums, with the employer picking up the rest. But laid-off employees who get Cobra coverage are responsible for 100% of the cost, plus an additional 2% for administrative expenses.

For an employer plan, the average annual premium has shot to more than $12,500 in recent years, and for individuals it’s over $4,500, according to surveys by the Kaiser Family Foundation and the Health Research & Educational Trust. Because of that, only a relatively small share of employees who are eligible for Cobra benefits generally choose to take them.

However, if you were laid off between Sept. 1, 2008, and the end of 2009, you might qualify for a federal subsidy that would help you pay to keep workplace health insurance for nine months. Congress may potentially extend this initiative. To learn more, check the Kaiser Family Foundation’s Web site and search for Cobra or look at the Web site of the Internal Revenue Service.

You may also save some money by choosing to cover only certain family members under Cobra, but the rules are complicated, so check with your employer benefits manager. Another key thing to know: Once Cobra coverage runs out, insurers may be required under federal law to sell you another policy, though there’s no guarantee on the price. But different states implement this rule in different ways.

Buying coverage on your own. Big insurers including have been rolling out a greater variety of plans, letting consumers select among an expanding menu of benefits and prices. This variety is an advantage of the individual market, since you may be able to tailor the plan to your needs.

Premiums for policies people buy on their own vary widely by state and by the age of the applicant. Average costs tend to be lower than those for employer-sponsored group plans partly because benefits in individual-insurance policies are often more limited and the plans may have higher charges such as co-payments.

But the individual market has several big downsides. If you’re older or have any preexisting health conditions, you may find it difficult or expensive to buy a plan. Also, you need to check the fine print to make sure you understand what the plan does and doesn’t include. If you don’t shop well, you can find yourself on the hook for big charges you didn’t expect, or with scanty coverage in the case of a serious illness or injury. Read the wsj.com Health Guide entry about buying individual insurance for more pointers on how to shop for a plan.

Government safety net. Consumers with modest incomes should check whether they or family members might be eligible for government coverage. The requirements to qualify for Medicaid and the State Children’s Health Insurance Program vary by state. In most states, SCHIP can be available for kids in families with incomes twice the federal poverty level, which was $21,200 in 2008 for a household of four in the mainland U.S.

If you have a preexisting condition and can’t purchase health insurance on the individual market, many states have high-risk pools. These are often very expensive, and they may have other downsides, including that they won’t cover expenses related to your preexisting condition for the first several months. You can learn about your state’s program at from the National Association of State Comprehensive Health Insurance Plans Web site.

Doing without health insurance should be a last-ditch choice. Beyond the obvious risk of sickness or accident, there is a hidden cost. If you spend more than 63 days without coverage you lose certain legal protections. For instance, a new employer can impose a waiting period before it covers your preexisting conditions.