Know Before You Go – Tips for being your own healthcare advocate

Healthcare can be confusing and expensive. That’s why you (or someone you trust) must be your advocate. Yes, your provider is part of your team, but you have choices. Your provider can make recommendations and referrals, but ultimately, you as the patient have the choice of who you see for specialty care, where you have your lab work or imaging performed, and other screening procedures. So, for you to make the best choices for you regarding your healthcare and financial needs, you first need to educate yourself.

Being your own health advocate empowers you to make informed decisions about your healthcare and optimize the financial aspects of your medical care, ultimately leading to better health outcomes.

When you choose a healthcare provider, factors that may be considered are location, accessibility, telehealth options, extended hours, and same-day availability if needed.

For many of us, economic considerations are important as well. Here are some tips to help navigate the expense of healthcare.

1. Understand your insurance

• Your health insurance may offer discounts when you see certain “in-network” providers. Check your insurance website for a list of providers that are “in-network.” If you are traveling outside your “home” area and need care, contact us and/or your payer to see if they will negotiate a single case agreement so you can receive care yet avoid an out-of-network penalty. By selecting an in-network provider, you are responsible for a co-pay and your insurance will pay most of the cost. You can call your insurance company or visit their website to help you determine what providers are in their preferred network.
  Using a provider outside of your provider network will make you responsible for a larger portion of the bill. ⁽¹⁾
• Know how to contact your insurance company either by phone or online to ask any questions you may have about coverage before your provider visit.
• Know your co-pay
• Know your deductible
• Know your co-insurance
• What preventative care does your insurance cover (ie annual physicals, vaccines, screenings)?
• Here are some key billing and insurance terms you need to be familiar with.

2. Research Costs

If you’re given treatment or screening recommendations, research options online before you have the procedure done.

All U.S. hospitals are required to publicly post charges for the most common hospital-based procedures, services, supplies, prescription drugs, and diagnostic tests, as well as fees associated with equipment or facilities used during a patient’s appointment or inpatient stay. Hospitals are also required to display at least 300 shoppable services. Standard Charges and Shoppable Services for UNC Health Appalachian can be found here.

For hospital services – including lab work and imaging – you may also request an estimate by calling 828-262-4111. Select Option 3.
For estimates at a Primary Care Office (PCP), see #3.

3. Ask for an estimate before you see your Primary Care Provider

For routine, in-office procedures, the office manager, registration supervisor, or front desk staff should be able to provide you with a cost estimate for most (not all) in-office procedures if you call 3-5 days before your visit.

However, keep in mind that lab work and testing performed outside the provider practice may result in additional billing, which may not be included in the office manager’s original estimate. You should also let your provider know if you or your insurance has a preferred lab. Other charges may also be added to your original estimate if the nature of your visit changes from what was originally scheduled. For instance, if you schedule an annual check-up and during that time you mention that you also need to be treated for a sinus infection while you’re there, your physical exam will transition to a problem-focused visit, and you will then be subject to a copay or patient liability (deductible / coinsurance). This is a common practice for all PCPs that accept insurance. Chart documentation is governed by compliance guidelines.

Providers must document their services, and coding and billing are generated based on this documentation. Organizations are required to bill for services performed and documented.

An estimate is the predicted amount you will pay for a defined medical service based on the information we have at the time the estimate is created, including your insurance coverage and historical data on what a typical patient has been charged for the medical service.

Estimates are for informational purposes only and are not guarantees of your final out-of-pocket cost for the service. Your actual costs may be different based on changes to your health plan design, deductibles/co-insurance and out-of-pocket limits, the clinical services provided, and/or the location you’ve selected. Estimates from your UNC Health Appalachian Associates office only include the fees charged by them. ⁽²⁾

Other factors that also affect the estimate result include:

• Preventative services: Services that may be covered at 100% by your insurance carrier (ex. mammograms, colonoscopies) – to determine what is defined as preventative, click here, or contact your insurance provider
• Visit severity: Services that vary based on the complexity of the problem.
• Comorbidities: Patients with more than one chronic condition (ex. Hypertension, diabetes)
• Complications: Unforeseen issues that may occur during the delivery of care (ex. Sepsis)
• If you are a self-pay patient -Self-pay patients who do not have insurance coverage will receive a 40% discount on services. Note: If patients have insurance coverage and elect to self-pay (do not bill insurance) they do not receive a discount and will be required to pay 100% cost of services if not filing to insurance.

Additionally, separate services provided during the same visit (ex. deliveries and newborn care) and services that depend on what your care provider finds during your visit (ex. routine colonoscopies vs. colonoscopies with a biopsy or lesion removal) may require multiple estimates to obtain a better picture of your expected out-of-pocket costs.2

In addition to the office manager and front desk staff, you can call UNC Health Appalachian at (828-262-4111. Select Option 3.) Mon-Fri 8:30-4:30 PM and speak with their estimate team.

You can also review some estimates using MyUNCChart.

4. Establish yourself with a primary care provider (PCP) and visit them once a year for an annual check-up or physical.

Having an established medical home has many benefits. Not only can PCPs help manage acute medical needs when they arise (i.e., flu, sinus infection, pink eye, sprains, UTI) annual check-ups and screenings can help detect or prevent serious medical conditions like cancer, diabetes, and heart disease. If chronic medical conditions are present, PCPs help manage those and serve as a hub and a referring provider to other specialists or surgeons if needed. Additionally, the cost of an established patient visit like an annual physical is less expensive than the cost of a new patient visit.

Under the Affordable Care Act, health insurers in the U.S. must cover certain preventive healthcare without requiring you to pay a deductible, copayment, or coinsurance. That rule applies to all non-grandfathered major medical plans in both the individual/family and employer-sponsored markets. This applies to services documented, coded, and billed under preventative guidelines/diagnoses. However, if a patient discusses additional health concerns and problems this would then become a problem-focused visit versus routine physical.

Learn what you can expect from a routine physical exam.

5. If there is a billing discrepancy ask questions.

For questions about your bill, call 984-974-2222.

6. Financial Assistance

We understand medical bills are often unplanned and can be difficult to understand or pay. UNC Health Appalachian has Patient Financial Advocates who are professionally trained to assist with your financial questions. The Financial Counseling Department is also available to help patients who may have difficulty repaying their medical debts. Patients can apply for financial assistance through UNC Health. Eligibility for this program is income-based.

For more information call 828-262-4110.

Also, the clinics in Avery County (Baker Center, Tate Clinic, Elk River Medical) participate in the rural health sliding fee scale. This provides a discount based on income for services provided at these clinic locations.

We at UNC Health Appalachian are in your corner. We not only want the best healthcare outcomes for you as our patient, but we also want you to have all of the information you need to make informed decisions about the financial aspects of your medical care.

⁽¹⁾ https://www.investopedia.com/articles/pf/08/cut-medical-bills.asp
⁽²⁾ https://www.unchealth.org/records-insurance/price-estimates