Preparing employees for surprise medical bills

When employees get sick or injured, the last thing they need is a jolt to the heart when medical bills start rolling in. Yet surprise bills are becoming more common.

As an employer, you might feel powerless to help an employee deal with a financial blow of hundreds or even thousands of dollars. But you can help, or rather, there are specialized employee advocacy centers that can offer assistance.

The doctors who charge the most are typically those that a patient did not choose. A seriously ill or injured person who is rushed to the emergency room may not be in a position to check if the anesthesiologists, ER physicians, neurosurgeons, pathologists and radiologists are all in-network. Researchers from the Yale School of Public Health and the Yale School of Management reviewed more than 2 million ER department visits and they found that one in five patients who used in-network emergency room facilities were actually treated by an out-of-network doctor. This exposed patients to additional, and sometimes huge, charges that were not covered by their medical plans.

A recent study in the Journal of the American Medical Association found that the average physician charges about two-and-a-half times what Medicare pays, while some charge up to four times more. Insurers typically use Medicare payments to determine what they will reimburse patients. Out-of-network physician referred by the in-network doctor also drive high costs.

The problem of surprise medical bills is becoming a fact of life for many employees, as insurance networks narrow and eliminate coverage for out-of-network services in an effort to save costs. This can put employers in a tough spot. Employees could get stuck with a hefty medical bill several weeks — or even months — after getting care. Then they come to HR or their benefits department for help deciphering a bill or a complicated explanation of benefits statement.

Benefits advocacy services, as stated above, are often provided by health insurance brokers. A strong employee advocacy program can help employees navigate a high medical bill and even intercede to reduce a bill for emergency healthcare services.

Benefits advocates can also help participants review their insurance plans before a procedure to determine what the plan will pay. Figuring out who’s in network and who isn’t ahead of time is critical to keeping the cost down.

Emergency care coverage can be difficult to manage because it’s nearly impossible for which to plan. Sometimes care is provided by an out-of-network hospital because, well, it’s an emergency. I know of a case where a benefits advocate stepped in and helped an employee recoup several thousands of dollars following his treatment for a major heart attack. The man was rushed to the closest hospital, which was out-of-network. Then he received a bill for $21,000.

The benefits advocacy center filed appeals with the carrier on behalf of employee and arranged for bills and collection notices to be held until the appeal was resolved. The advocacy center also provided the carrier with information about other insurers’ policies of covering emergency care as in-network.

It was a happy ending. The carrier agreed to cover the admission as in-network. Imagine the relief the employee felt when learning of the $19,000 decrease in his out-of-pocket expenses. The carrier even revised its policy to cover emergency care at in-network levels, regardless of whether the hospital participates in the network. That’s the real power of benefits advocacy: helping an individual and also working to improve the system.

A little knowledge

Advocates can “pre-educate” employees on what emergency care is covered and which area hospitals will take their insurance. They help employees get an estimate of the cost of medical treatment before it’s delivered. Many carriers have online cost estimator tools where employees can see how much they’ll be responsible for. Doctors also can provide an estimate and detail the specifics of a procedure, as well as answer patient questions ahead of time. It’s a good idea for the employee to gather written cost estimates in advance.

If the bill comes in much higher than expected, the benefits advocate can investigate. The bill could be coded improperly or the insurance payment may not have been credited appropriately. Benefits advocates research a bill and cut through the red tape to get answers from carriers and providers faster than employees. Advocacy centers often have a direct line to carrier and provider decision-makers that an employee wouldn’t have access to.

If the bill is accurate, it is still possible to negotiate and employee advocates can help. Most medical practitioners will accept a reasonable negotiated price to ensure they get paid for part of the cost. The employee might also work out a payment plan with low or no interest.

The healthcare landscape will continue to get more complex in the foreseeable future, all while putting more responsibility on individuals to understand their insurance options and make educated decisions. Employee benefits advocacy can turn insurance users into savvy insurance consumers, long before they pass through the sliding doors of an emergency room.