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Weekend Check-Up


June 16, 2018


Understanding Healthcare Prices: A Consumer Guide


By Taylor Stonerock, Business Office DirectorTaylor Stonerock


Maneuvering through healthcare today is similar to running an obstacle course. It seems as though there are always new hoops to jump through and you never know what may jump out at you with regards to your responsibility for payments or authorizations.

At William Newton Hospital, we are dedicated to improving patient interaction and are aware of the struggles associated with the recent changes made to healthcare coverage. We want patients to be aware of the options available to them regarding insurance coverage and the impact it can have on them.

There are a few common themes in the questions we receive regarding healthcare coverage in general. How much will this cost me? How do I know if a procedure is covered? Can I make payment arrangements? What insurance company should I sign up with? Some of those questions can be answered by staff at the hospital and some cannot. Let’s start with the ones we can answer.

How much will this cost me?

That answer may vary and will depend on the procedure and diagnosis codes involved. When a physician orders a service such as laboratory tests or a radiology procedure, there are specific current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) codes that inform your insurance company what procedure was provided, as well as diagnosis codes that explain why a procedure was performed. The CPT/HCPCS code is specific to the procedure performed and the diagnosis code is supplied by the ordering physician. Insurance companies have strict policies on what procedures and diagnosis codes they will cover and if you have questions regarding what they will cover you can call the customer service phone number on your insurance card. You may also call and request an estimate from the provider, such as a hospital or physician, but you must understand that it is an estimate. It may not reflect your total bill after services are provided.

Your responsibility is also determined by the type of coverage you have and whether or not that insurance is in or out of network with the provider of services. Insurance companies price their claims based on what level of coverage you enroll in (high or low deductible, consumer or flex spending, etc.) and whether or not they are contracted with the facility or physician providing services. If they are contracted, the facility/provider is in network which generally results in lower patient out of pocket expenses. 

There are different levels of patient responsibility: coinsurance or cost share, copay, deductible and non-covered. Most insurance companies provide you with your maximum out-of-pocket expense but you can always contact them for those limits. You can also contact them to find out if a service you are considering having performed will be covered. There is a portion of most billed claims that are left to the provider’s responsibility called ‘contractual obligation.’ That amount is anything above what your insurance company allows and will not be left to your responsibility. If you have any questions about the amount left to your responsibility when you receive a bill, please contact that provider for clarification. Questions about your bill with William Newton Hospital can be answered at (620) 221-2300. Please request the business office.

Can I make payment arrangements?

Often when you receive a bill the full amount is requested to be paid. It is understood that paying a balance in full is not always feasible, so some providers will work with you to set up payment arrangements. Most providers have guidelines and policies on how quickly a bill is to be paid in full, so please contact that provider for questions regarding payment arrangements.

What insurance company should I sign up with?

William Newton Hospital staff are not able to help patients decide which insurance they should obtain coverage from. There are different resources available to assist you in your coverage decision. If you have questions about a Medicare replacement or supplemental plan you can contact your County Council on Aging. If you have questions about commercial coverage you can contact the Insurance Marketplace for assistance.

For more in depth information on navigating healthcare coverage and prices view a digital copy of HFMA’s “Understanding Healthcare Prices: A Consumer Guide” or order a hard copy.

The "Weekend Check-Up" is a regular health column published in the Cowley Courier Traveler penned by employees and friends of William Newton Hospital.