How To Read Your Medical Bill

by Gerri Willis

There was a time not that long ago that a patient might never see a medical bill, much less have to read it. But few of us can afford to be blissfully ignorant anymore, as rising costs force insurers and employers to push higher deductibles and co-pays onto consumers.

What’s worse, once you get your bill, you may well decide it’s written in a language you don’t understand. Bills are chockablock full of complex coding and shorthand that insiders hope you never really understand. That strategy is working so far. Fully 77 percent of Americans say they don’t understand either the medical bills they receive or their health insurance. But it pays to be persistent. According to Medical Billing Advocates of America, 80 percent of medical bills contain some error. And, the most common ones are duplicate billing, typos in which the wrong coding or price is entered, charges for work that was cancelled and inflated operating room fees.

Of course, these errors could be in your favor or against you, but either way, you’ll want to know if your bill is simply wrong. Here’s how to read and understand your medical bill:

  • First off, understand that your charges can come from a variety of different sources, such as your doctor for the exam, the lab for testing and say, maybe radiology for services. The list can go on and on. Different sources means the possibilities for mistakes and errors escalates.
  • The second thing you’ll notice on an itemized bill from your doctor or hospital are five-figure codes. These are called CPT codes (for Current Procedural  Terminology). These codes are assigned to each and every service a primary care physician, specialist or technician provides a patient, including medical, surgical and diagnostic services. You can understand what these codes mean by going to the American Medical Association’s CodeManager on their website here ( . You’ll have to fill out some details about yourself and promise not to use the information for anything but your personal information. But going to this extra trouble will allow you to see precisely what you are being billed for. Remember that some health care workers spend their entire careers mastering the CPT codes. So if you’re having trouble understanding them, ask your doctor’s office for details.
  • Suffice it to say that the story of what you pay doesn’t end with the doctor’s bill. You’ll also receive an EOB or  Explanation of Benefits, from your insurer or Medicare. It will show how much of each service was paid for on your behalf. Like the doctor's bill, each service coded. You’ll want to verify that the CPT codes on your doctor’s statement match the codes on the insurer’s statement to be sure that you’re being charged for the services you are receiving. If they don’t match, contact your doctor and the insurance company.
  • Let’s talk about the bottom line. So, at the bottom of your final bill, you’ll see a line item called the “charge.” Consider this the sticker price and not the final price. The discounted price or “adjustment” will follow, which will factor in anything you’ve already paid from your co-pay to deductible or insurance.  The “balance” (sometimes called the Patient Responsibility”) is your final bill with whatever late fees or credits may have been paid.


When to Change Doctors

When to Change Your Doctor

by Gerri Willis

People spend more time buying a car or choosing furniture than they do picking a primary care physician, according to the American Institute for Preventative Medicine. Not only do consumers do little due diligence in choosing a doctor, but they are unlikely to change doctors voluntarily. Don Powell, AIPM president, says even if a doctor is no longer in a patient's network, many people are reluctant to switch. They're nervous of offending the doctor and they are reluctant to dump a physician who knows their history. But here is the new reality: As insurance companies consolidate and networks change, being forced to find a new doctor is much more likely. What’s more, as you change and age the doctor you originally chose to serve your family may not be the right fit anymore.

Choosing a new doctor isn’t as easy as it sounds. In fact, with some 850,000 doctors out there, it can be overwhelming to find the right match for you.

Here are the key factors to picking the best doctor for you:

  • Start your list with the doctors that are inside your insurance network. Picking a physician outside your network is a recipe for financial disaster. That’s because you will likely end up picking up all or most of the total bill for every single visit even if you are simply getting a flu shot. If you figure that the average cost per visit is $200 and the average family of four goes to the doctor’s office 16 times per year, you could be facing a hefty $3,200 tab each and every year. Much better to make the average $22 co-payment. Columbia Presbyterian ophthalmologist Dr. Pamela Gallin advises patients to pick doctors affiliated with the best hospitals in the area, otherwise, she says, you can be facing even higher costs for using a facility not associated with your insurance provider. Keep an eye on the affliations of any specialists you see as well.
  • Solicit advice from friends and family.  Often, those closest to you have experience with local doctors. Ask them the questions that are difficult to answer: Is their doctor responsive? Do you spend hours waiting to see the doc? Since the average physician interrupts his or her patients just 23 seconds into their description of their ailments, ask whether he or she is a good listener. Does the physician take questions by email? How nice is the office staff? When you’re sick and seeking care, all of these issues take on greater importance.
  • What’s his or her credentials? Credentials matter and many of them have to be periodically updated. A gynecologist, for example, has to pass a written and oral certification every six years with the American Board of Obstetrics and Gynecology. Your insurers’ website may give you basic information on the educational and professional backgrounds of their member physicians. If not, check out these: 1.) Administrators in Medicine ( provides information on licensing and disciplinary actions for doctors in 18 states. 2.) American Medical Association’s DoctorFinder ( has comprehensive information on member doctors including their educational background and areas of specialization.
  • Check out online patient reviews. Sites like or rank doctors based on patient reviews on easy to use websites.




How to Get the Most Out of Your Insurer

How To Get The Most Out of Your Insurer

by Gerri Willis

Even if you have terrific health care insurance from your company, you know this: Your out of pocket costs are rising. In just six years, the average annual amount you pay for health care has risen from about $2,000 to $3,400. Have a family? You’re looking at even more money. And, the prospects are getting worse, not better, as Obamacare is phased in.  One major insurer recently revealed that consumers buying their own plans could see prices rise 116 percent from current rates. Small business rates, they said, will go up 25 percent to 50 percent. These days, whether you’re buying your own policy or getting coverage from your employer, it’s clear that more and more of your take home pay will be sucked up by medical bills.

Behind the scenes, doctors say they struggle to get reimbursed by insurers to cover their costs of care. Dr. Pamela Gallin, a pediatric ophthalmologist at Columbia Presbyterian, says the excuses she receives from insurers run from “We didn’t receive your paperwork” to “You didn’t fill out the paperwork correctly.” Or simply, “You’re not covered anyway.” 

In fact, there is a war on between insurers and doctors. Behind the scenes, an entire industry has grown up to advise medical offices on how to apply for reimbursement. Gallin says doctors spend hours learning about the complicated coding required insurers to successfully file a claim. There are seminars, books and even newsletters describing these codes, which she compares to SKU numbers on products in stores.  File too aggressively and ask for too big a reimbursement, called “coding up,”  and the doctor’s office is subject to fraud charges. Ask for too little and the doctor’s costs aren’t reimbursed.

Hospital groups are putting the pressure on too for savings using “big data” to monitor doctor’s work. The move is possible because of Obamacare requirements that patient data be made electronic.

The upshot of these trends is that consumers are stuck in the middle, and often stuck with bigger bills.

“The insurers don’t want to pay and hospitals and doctors do want to be paid and the patients would like to have their services covered,” says Gallin.

Getting the best outcome, then, can be tricky:

  • Read your insurance policy. Okay, so you may need some Sominex, but reading the policy is the only way you’ll know what you’re covered for and can manage your care.
  • Check for grandfathered exemptions. Obamacare requires insurers to cover some procedures and tests that some private plans don’t.  Changes to coverage won’t happen immediately. Don’t assume your plan automatically expands coverage.
  • Be aware of changes. Not only in your insurance coverage, but also your own health needs. Benefits change overtime, so make sure you’re continually reviewing your health insurance plan. Along with the policy changing, your needs change over time, too. Take into account starting a family, or having kids out grow your insurance plan. Make sure your plan will cover what you need through life.
  • Seek help. If you are lucky enough to have your coverage provided by an employer, use their leverage to help get your bill paid. Your human resources department can run interference. If you aren’t in a corporate plan, hire an advocate to take up your case.  Health care advocates exist across the country and usually take a percentage of any settlement they get for you.
  • Understand deductibles. The amount you pay out of pocket before your insurer starts picking up the tab can be confusing. Understand this, the tab you get from a doctor for a service or test may not be applied to your deductible in its entirety. An insurer will credit you for less – say, the costs that Medicare would reimburse plus 10 percent. As an example, let’s say you run up a $250 bill getting an exam from your primary care physician. An insurer may credit you for the amount Medicare would reimburse the doctor for a similar service, say $80, plus another 10 percent. Not $250. Plus, you may have multiple deductibles, one for medications, another for your provider’s treatments and yet another for hospital treatments.
  • Stay in network. There’s only one source of funds for doctors that are not in your insurance network and that’s your pocketbook. Before opting out for an out of network specialist, carefully consider the costs.

ALL THIS WEEK: User's Guide to Health Care

User's Guide to Health Care

by Gerri Willis

It’s a small wonder that the process of getting quality health care in this country can be a frustrating experience. That’s because you are pitted against a sprawling $2.6 trillion health care industry that commands a fifth of total economic spending in this country. It’s a little like the Lilliputians trying to control Gulliver. Darn hard.

The business is also becoming ever more conscious of its bottom line. In a world driven by complicated Obamacare rules and regulations, doctors are searching for cover. Many are finding welcome partners in hospital groups that are expanding market share.  Moreover, insurers were already in merger mode even before healthcare reform was signed into law. In the state of Rhode Island, for example, Blue Cross & Blue Shield control 95% of market.  The result of all this consolidation? Less choice and fewer options for consumers.

It’s not just you against industry bean counters, it’s also you against the government, which controls roughly half of healthcare spending in the country through programs like Medicare, Medicaid, the Veterans Administration and CHIP.  Government bureaucrats’ deep involvement in this industry results in whimsical pricing – especially for the uninsured.  Want a Tylenol? If it’s dispensed in a hospital, a single Acetaminophen tablet could cost $1.50. For $1.49, you could get an entire bottle of the stuff at your local drug store.

The trouble doesn’t stop at getting a government or private sector insurer to approve your claim. Getting the best care from your doctor is no simple prospect.  Patients spend nearly twice as much time on average waiting for their doctor than actually talking to him or her. Once you get past the waiting room, the average doctor visit lasts just 10 to 15 minutes. And, if you thought you’d find an eager listener to your health care concerns, well think again. The average patient gets interrupted just 23 seconds  into describing what their medical problem is -- by the doctor, no less. The old Marcus Welby-style of practice – sit, listen, evaluate – is long gone.

All of this might be passable, if the country could boast the best care in the world. Unfortunately, it can’t. Of 17 high-income countries studied by the National Institutes of Health this year, the U.S. had the highest or near highest prevalence of infant mortality, heart and lung disease, sexually transmitted infections and disability. The U.S. is at the bottom of the list for life expectancy. Men in America live shorter lives – four fewer years – than in other wealthy developed nations.  And, yet we are paying more for this care than those in similar countries, an average of $8,402 per year per person. In other words, more spending, worse results.

Tune in all next week as we explore these critical issues. Email us and join the discussion on and


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