North Carolina Department of Justice

North Carolina Department of Justice

North Carolina Department of Justice
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Make the most of your health care coverage

4/30/2007

By Attorney General Roy Cooper
 
It’s no surprise that complaints about health care and health insurance have topped the list of the most common complaints to my office over the last few years. In 2006 alone, more than 5,000 North Carolina consumers filed complaints or made inquiries with us about problems with health insurance, doctors, dentists, hospitals, pharmacies, opticians, nursing homes, and health products and services.
 
As health care costs continue to rise, consumers are paying more. Many consumers are finding themselves stuck with a hefty bill for medical care even when they have health insurance. Here are some suggestions to help keep your medical bills manageable.
 
Ask questions first.
 
  • If you have insurance, ask your insurer—not your doctor—what you’ll pay out of pocket for a particular service or treatment.  Is the procedure covered by insurance? Does it require prior approval? How much is your deductible? Will it apply to the service? What about other fees like copayments and coinsurances?

 

  • If you don’t have insurance, find out about costs up front. Ask if the hospital will negotiate and accept less than their requested amount, and get any payment arrangements in writing. Ask if there are programs that can help you afford care, and be prepared to show proof of financial need to qualify.
 
Visit in-network providers. 
 
  • Generally, you’ll save money by seeking care from doctors and hospitals that are in your health insurance network. Get the names of the physicians and facilities you plan to use and ask your health insurer if they participate before you receive services. Don’t assume that a doctor or hospital is in-network just because they accept your insurance. 

 

  • Be aware that even though a hospital may participate in your plan, other physicians at the hospital such as anesthesiologists and pathologists may not be part of your plan. Check with your insurer to find out about these costs. 

 

  • If you feel that you must use an out-of-network provider, you can request an exception to cover the services at your in-network benefit level. Be sure to ask your insurance company before you receive the service.
 
Understand your rights. 
 
  • If your managed care insurer denies a claim or doesn't pay as much as you expected, you can contest the decision through the appeal process. If your appeal is denied after the first level, you may be able to seek additional reviews.

 

  • You’re entitled to a copy of the criteria the health plan uses to decide if the surgery, treatment, test or device is medically necessary. This information is sometimes listed on the company’s website, or call your insurer to ask for a copy.

 

  • You have the right to get a copy of your medical records unless the physician feels releasing them could endanger you or someone else. You may need copies if you’re planning to go elsewhere for treatment or want to appeal a denial from your insurer. Be aware that the physician or facility has the right to charge a reasonable fee for preparing and copying records.   
 
Understand your responsibilities.  
 
  • Take the time to understand your health insurance coverage. Contact your insurer to get a copy of your benefits, read them and ask any questions about your policy. 

 

  • Make sure the physicians, hospitals and other health care facilities you visit have your complete health insurance and contact information. 

 

  • Understand that medical care costs can be a heavy financial burden. Keep in mind that you can be sent to collections for medical bills even if you’re making minimum monthly payments towards the debt you owe.  
 
Know where to go for help.
 
  • Navigating the world of managed care and health insurance can be a confusing process, especially when you, or a loved one, are dealing with serious illness or injury.   [Services provided by MCPA have been transferred to the Health Insurance Smart NC Program.]
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Attorney General Roy Cooper and his staff want to make sure North Carolina consumers get treated fairly. We are here to be of service when you need us, but through consumer education efforts like these columns we hope to help consumers avoid problems from the start.