Navigating the Healthcare System My Healthcare Story and What I Learned

It was a Sunday morning in November and all of a sudden what began as a relaxing day turned into an ER visit followed by emergency surgery.  Fast forward five days and I was being discharged from the hospital.

Obviously, my health and recovery were my first concerns, but once the pain meds wore off, I started wondering what this would cost me.

(Apparently, I wondered this at the hospital, as my husband recalled that I asked the surgeon if he was “in network.”)

Until this episode, I had accumulated $1273 dollars of medical costs that mostly included physical therapy and some minor x-rays.  No concern at all about nearing my deductible of $5,500 or Out of Pocket Maximum (OOPM) cost of (gulp) $8,700.

I am an accountant by training so I should be able to figure this all out, right?  No sweat!

Then the EOB’s started to come, followed by bills from the providers.  Because of the multitude of specialties that were involved in this episode of care, I received no fewer than 20 EOBs from seven different providers.  Seven of the EOB’s were adjusted and re-submitted.

So of course, I loaded them all into an Excel spreadsheet to sort it all out and make sure I did not pay more than the $8,700.

Checking and re-checking my formulas, it just wasn’t adding up.  According to the EOBs, the total I was responsible to pay was $10,300, or $1,600 more than my $8,700 out of pocket maximum.

I called my insurer and asked “Which claims do I pay?  If I add them all up, I am over my OOPM?”  There was an uncomfortable silence on the other end of the line, as he was trying to come up with a response other than “Bless Your Heart.”

Fast forward another two months and I think we have figured it out.

Here are some lessons I learned:

All parties involved want to resolve outstanding medical bills.

I don’t like conflict, but I can be quite persistent, especially when I know I’m right.  I dreaded calling the insurer to resolve my issues.  I also dreaded the follow up visit to my doctor when the office staff presented me with an invoice (that I thought the insurer should pay).  But I found both parties to be very patient, willing to listen and resolve my issues.  It helped that I was prepared with specifics when we spoke.  At the end of the day, the insurer, providers and I all wanted the same results – appropriate payments according to the contracts we entered into. (I don’t think they like conflict, either.)

Don’t just throw away or file an EOB form.  Understand what it means.

Explanation of Benefits (EOB) forms can be confusing.

Each time a health care provider provides service to you, they submit a claim to your insurance company.  The insurance company sends you an EOB, that describes the service, the total amount billed by your provider, the amount your insurance company will pay, and the amount you will be responsible to pay.   The EOB includes a lot of information, so let’s look at what it all means.

The “Amount Billed” is the what the provider charges at 100% (“think Full Retail”).

Providers and the insurance company negotiate a fee schedule for every procedure.  So, when a provider agrees to accept your insurance, he or she agrees to be paid this negotiated amount, which is less than the amount billed.  This discount is shown on the EOB as “Discounts and Reductions.”   The discount is often substantially less than full charges.    The amount billed less discounts and reductions is the “Amount Covered/Allowed.”  This is what will be paid to the provider for the service, either by the insurance company or you. 

The rest of the EOB reflects what the insurer will pay, based on the terms of your policy.  What remains is your responsibility to pay.  “Your Total Costs” include co-pays, deductibles, and co-insurance.  This is important because these costs comprise your OOPM.

If you receive corrected EOBs, match them up with the original ones so you know what changed.

Keep track of your out-of-pocket costs as you incur them throughout the year.

Know what expenses count against your deductible and out of pocket maximum expenses.  For example, co-pays do not count toward the deductible, but they do count toward the OOPM.  Who knew?

After each medical treatment or visit, review where you stand with your deductible and OOPM cost.  This might seem unnecessary until you actually reach your deductible or OOPM.  But I waited until after I reached mine in November to try to sort it out.  It was overwhelming due to the number of claims filed simultaneously for those six days.   Your insurer can tell you how much of your deductible and OOPM have been met, either via telephone or on-line.

I used my on-line account with the insurer to track my YTD costs toward the deductible and OOPM.  Each claim and all the costs were displayed on-line.  This provided an excellent starting point.  I then tried to understand why my calculations were different.  It took several telephone conversations with my insurer, but here’s what we found:

  • Co-pays did not count against my deductible, but they did count against the OPM.

I had erroneously applied the amounts of my co-pays toward the deductible.

  • Some services were not paid by my insurer because they were not pre-approved.

These were two PT visits.  Make sure you receive a referral for specialty care if your plan requires it.

  • One provider was considered out-of-network by the insurer, even though he was listed in their Provider Directory.

I wanted this physician to be paid what was due him, but couldn’t understand why it was my responsibility, and not the insurer’s.  The insurer had an old address for him, and he was shown as out-of-network at that address.  If possible, make sure your provider is in-network (a participating provider) before you seek care.  Approach this from two angles.  First, call the provider and inquire if they take your insurance.  Give him your plan name, member ID and group number.  Second, look up your plan’s provider network on-line.  The providers in network are listed by type of care (hospital, primary care, specialty, etc.)

Why is this important?  With an insurance policy like mine, an HMO, I pay more out-of-pocket if I use an out-of-network provider.

Out-of-network costs do not count toward your in-network deductible or OOPM.

Some policies do not pay for non-participating providers.  If they don’t, there is no deductible limit or OOPM for their services.  If they do, there is a separate deductible and OOPM.  For me, those amounts are nearly triple those for in-network care.

  • There is new legislation that provides billing protections when getting emergency care, and non-emergency care from out-of-network providers at in-network facilities.

This is huge!  Obviously, if you need to go to the ER, you might not be in a position to question whether the hospital and physicians are in-or-out-of-network.

Last time I went to the ER, the hospital was in-network, but the ER physician group was out-of-network.  I received a bill for the difference between the group’s billed charges and what the insurer paid them.  This is known as a “balance bill.”    An unexpected balance bill is appropriately called a “surprise bill.”  I fully expected to receive the same type of bill this time around, but the bill was discounted to the insurer’s contracted rate.  What happened?

New Federal legislation, effective January 2022, does two important things.  First, it bans out-of-network cost sharing, like copays and deductibles, for all emergency and some non-emergency services.  So, you can’t be charged more than the in-network amount by an out-of-network provider.

Second, it bans out-of-network charges and balance bills for supplemental care, like radiology or anesthesiology, by out-of-network providers who work at in-network facilities.   Basically, the group applied the insurer’s discount to their bill.

  • Wait until your insurer processes your EOB before you pay the provider.

As I mentioned above, I had 20 EOBs from seven different providers during my hospital visit in November.   Several claims were filed for each date of service, which made prioritizing payment confusing.  As my insurer re-processed the claims in question, they also re-processed and re-issued the EOB’s from those claims, and any claims after that date.  The cumulative amount of my out-of-pocket expenses changed accordingly.  As did the date I hit my OOPM and the claims that comprised it.  So, some of the EOB’s that originally showed a payment due from me were adjusted downward to reflect what insurance paid.  Many of these corrected EOBs reflected $0 payment due from me.

Because I like to pay my bills on time, I had already paid one of the providers $242 that the insurer subsequently paid.  The provider owed me a refund.

If you feel you have overpaid a claim, be proactive and call your provider.

Funny thing about that $242 refund the provider owed me.  I suspect it would have not been refunded had I not called the physicians’ billing office and inquired about it.  They agreed with the amount to be refunded, but only showed it as a “credit” to my account.  I get it when I accidentally pay a utility bill twice, and the company applies my overpayment to the next month’s bill.  But I didn’t expect to have recurring charges from this provider.

I asked the billing office if they would have issued the refund had I not called them.  The nice man on the phone basically said no, that I needed to “be proactive” about asking for it.  So, I was, and should receive the credit “in the next seven to ten business days.”

Remember those EOB’s I mentioned earlier?  Had I not actually looked at the revised one and matched it with the original, I never would have noticed that the insurer paid the $242.

If you have questions about a claim, call your insurer’s member services.  They can access the information and advise you how to proceed.  Before you do, I strongly recommend that you enroll in your insurer’s on-line access account.

Most of the information you need will be there.  I visited my on-line account several times as the EOBs came.   I found a lot of valuable information, including summaries of each claim, its status as processed or paid, and the total I incurred against my deducible and maximum out of pocket.   By viewing this information before I called the insurer, I was able to organize my thoughts and questions based on specific claims data.  The more specific, the better.  Looking at this information real time as I spoke with my insurer’s representatives was invaluable.  They could see exactly what I was looking at and why I had questions.  One representative actually sent me a spreadsheet of my claims, highlighting those that were applied to the OOPM, those that were still under review, and those that were adjusted based on our conversations.


As of today, I have paid exactly $8,700 of my $8,700 OOPM.  I know exactly which claims comprise it, itemized of course on my Excel spreadsheet.

My insurer has paid the claims in excess of that amount.  As far as I know, all the providers have been paid what was due to them.  And hopefully I won’t get anywhere near my OOPM in 2023!

Lessons Learned

  1. After your healthcare service, make sure you know and make sure:
    1. Your Health Insurance benefits.
    2. How much monies have been applied to any deductibles.
    3. Whether the healthcare providers that treated you were in or out of your network.
    4. Match your EOB’s (Explanation of Benefits) to all bills you receive from healthcare providers.
      1. Make sure the payment is correct, in or out of network payments.
      2. Make sure your deductibles have been applied correctly.
      3. Maintain all EOB’s and bills you receive.
  1. If appropriate, create a log and track your insurance payments and you out of pocket expenses.
  2. If you have any questions call you insurance company or healthcare provider
  3. Most insurance companies have online services that track all your activity. Take advantage of this offering.
  4. Many healthcare providers will not automatically refund overpayments to you unless you ask.


By Angela Herron







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