Most consumers are aware that by utilizing " In Network Providers" with your Insurance Company you will have higher coverages and lower out of pockets costs. But there are so many ways to maximize your Insurance benefits coverages while decreasing your Out Of Pocket costs. By Being an educated consumer and yes sometimes having to take extra steps or making calls can in the end, save you money. Firstly, create a folder at home for matching up your Physicians billing with that of your EOB (Explanation of Benefits) claims processing receipt to ensure your providers office has not overbilled you. If you use a "Contracted/In Network Provider" they are locked into a contract for pricing. What does this mean? If your Doctor charged $100 for the exam and your EOB/Claim states their contracted price for reimbursement is only $50.00; you do not owe the $50.00 difference. They may bill you, but if they are In-Network aka Contracted, you do not owe the difference. SO before you cut the check to them, call your Insurance company and speak to a representative. Often times, they have provider and member Advocates who can resolve this with your providers billing (ask as they may not just offer this service until you ask). Secondly, if your Doctors mentions you need; a blood pressure monitor, a hospital bed, oxygen, a walker, a wheelchair etc. This is called Durable Medical Equipment or DME for short. Before you run out and pick it up from your local vendor, verify with your Insurance company who their local providers are (quick service and supporting the little guy) as well ask if the have National Contracted Providers. It can be time consuming but by calling the vendors and asking their pricing can often vary by hundreds if not thousands of dollars. This can ultimately affect your pocketbook and overall expenses and works for Prescription Medications as well. Thirdly, Follow up on your Physicians billing. Over the past few years, Physician offices have become create with their billing to try and maximize their income. Under Medicare and most insurances we are allowed 100% coverage for a 1 time in 12 months "Annual Wellness Examinations." This is covered under Part B of Medicare (Outpatient Physician Services). Whether you have Medicare or Insurance they process the same in claims. If you receive a bill and you owe MORE, you need to check the providers billing information and coding. They may have coded it incorrectly (follow up exam vs an Annual Wellness) or when you asked about the weather, that aching hip you have or any other medical questions; they can add that and "pad their bill." Again, often you have to be your own Advocate, question the bill, question the office billing staff and reach out to your Insurance claims department for accuracy prior to paying their bill. Finally, being a smart consumer takes patience & time but again, in the end can save you money.
Preparing for upcoming procedures can be stressful. But preparing for your financial responsibilities before, during and after your procedure is essential for your budget. If you are using an "In-Network" contracted provider, you can ask the provider #1 the billing code they will be using and their usual fee then ask your insurance company their "Usual and Customary fee schedule" for that specific billing code. Remember to call your Insurance carrier to verify if a "Pre-Certification" process for notification is required. For many diagnoses and surgeries, certain criteria must be met for "Pre-Approval or Certification" of your upcoming procedure. This may help avoid any Denial of Services or a delay in your procedure because it was not Pre-Certified. Be your own advocate and make the call to verify their rules, it is usually helpful to keep a log and track whom you spoke with for resolving any future issues.
The below Medicare link can give you a rough estimate of the cost. Please be aware, Medicare's reimbursement is significantly less than that of Insurance contracts for providers; often by multiplying by 1.5 or doubling Medicare's rate you will be in the Insurances ballpark of cost expectations.
Whether you are on a daily prescription medication, an expensive cancer medication, anti-rejection medications or a short term prescription of antibiotic. There are strategies for cost savings as some can be thousands of dollars a month. #1 use a Network or contracted provider. #2 for long term prescription medications, verify if your Insurance has a Mail in program. Sometimes buying in a 90 day bulk can save you money and you also have the ability of door to door delivery. Many local retailers are now offering "member savings" or discount programs with a Member Saving Card. For very expensive medication or specialty drugs, your Insurance may require you to meet certain criteria for coverage vs decide not to pay if that criteria is not met. They often will require you to do "Step therapy" requiring you to "try" other less expensive medications first and/or their Specialty Pharmacy Program as a gate keeper for their Cost Containment. Recently, a Bill was signed by President Trump to cut out high kickbacks to the middle man for prescription drug fees and sending the savings back to We The People. There soon will be more to come on that and the trickle down effect to us the consumer vs Pharmaceutical companies. And finally, if you are prescribed by your provider an expensive medication, most pharmaceutical companies offer a Medication Assistance Program. Reaching out to your pharmacist on how to apply if your Physician does not offer it to you can often provide you substantial savings. Not taking your prescribed medications, should not be the option because you cannot afford them. Reaching out to Social Workers locally or calling your pharmacist or the Pharmaceutical company can certainly offer resources to help you get the medications you need at a price you can better afford.
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