Understand your health care coverage
Many health care consumers don't take the time to understand their health insurance coverage before they incur medical expenses.
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Review the plan materials. You should review the plan materials frequently, and ask your employer or the insurer if you have any questions.
The time to address any confusion is now, not when you are facing a stressful medical situation and may have to make decisions quickly.
Understand your medical condition and the proposed treatment
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Being an informed patient includes learning about your medical condition, the medical procedure or treatment that has been recommended, and suggestions
on next steps. Take the time to research the medical condition and discuss questions with your physician.
Consider quality-of-care issues
South Dakota hospitals are committed to sharing information about the quality and safety of the health care services that they deliver
in their communities.
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South Dakota hospitals are committed to sharing information about the quality and safety of the health care services that they deliver in their communities. The South Dakota Association of Healthcare Organizations Quality Website provides reliable data on interventions that medical experts agree should be taken to treat heart attacks, heart failure and pneumonia, surgical services measures and error prevention goals.
Understand how much you will be expected to pay before receiving hospital care
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If you have health insurance, contact your insurer and:
Explain what is to be done, when it will be done, and by whom (hospital/physician).
The South Dakota Hospital PricePoint Web site provides information on billed charges for all types of inpatient care and selected outpatient services. However, lower hospital charges may not necessarily mean you will pay less out of your pocket. That is why it is important for you to contact your insurer.
Confirm that the procedure and the provider will be covered.
Ask if there are any limitations to the coverage.
Ask what the expected out-of-pocket costs will be.
Ask if the out-of-pocket costs would be less if a different hospital/physician was involved.
Many commercial insurance companies and employer self-funded plans require enrollees to seek care exclusively from a specific group of hospitals and physicians in order for the service to be covered. This group of hospitals and physicians is often called a “network.”
Other insurers and employers will cover the services of hospitals and physicians that are not in the network, but will require patients to pay a higher percentage of the cost if they use the services of non-network providers.
If you are required to use the services of physicians who are in your insurer’s network to receive the highest level of coverage, ask your insurer for the names of the anesthesiologists, pathologists and radiologists in the network who provide services at the hospital. These are the types of physicians who may provide services related to your inpatient stay or other hospital service, but it’s possible you may never personally interact with them. As with surgeons, they are often not employees of the hospital, so their services will probably be billed separately. If they are not part of your insurer’s network, you may be responsible for a larger portion of their fees or all the fees.
If you do not have health insurance:
Contact the hospital and ask about its payment policies. Hospitals have charity care policies that offer partial or total fee reductions, or payment plans, to patients who have a financial need. However, hospitals expect patients to cooperate in the eligibility determination process.
Paying for care
Hospitals will often accept amounts less than their billed charge as payment in full.
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For government programs like Medicaid and Medicare, hospitals are required by law to accept the payment from the government, combined with any required cost-sharing from the patient, as payment in full.
The same is true for most types of commercial health insurance, although it is not a matter of law but rather a matter of the contract the hospital has signed with the insurer.
For patients without health insurance, hospitals have charity care policies that offer partial or total fee reductions, or payment plans, to patients who have a financial need. While policies will allow consideration of individual circumstances, financial assistance provided by hospitals is not a substitute for personal responsibility. Patients are expected to provide complete and accurate information about their financial status and to pay for their care based on their individual ability. In this way, applications for charity care can be accurately assessed, assistance can be managed fairly, and hospitals can meet their mission to provide care to all patients.
Hospital Bills vs. Physician Bills
It is important to remember that although physicians provide services at hospitals, most of them are not actually employed by the hospital. This means that the cost of their services would normally not be part of the hospital bill.
You (or your insurer) should normally expect to receive separate bills for “professional” charges (from physicians) and facility charges (from the hospital).
Most types of insurance do not pay the entire cost of health care services. They usually require patients to pay part of the cost through deductibles, copayments, or cosinsurance.
Deductible: A deductible is a specific dollar amount a patient must pay for covered services before the insurer pays benefits under the policy. A deductible usually applies to all covered services under the policy, although in some health plans certain services (like preventive or well-child care) are not subject to the deductible. Sometimes deductibles apply to only to specific types of services, like hospital inpatient care or durable medical equipment.
Copayment: A copayment is a per-service deductible. Health plans will often require a copayment for physician office visits or prescription drugs.
Coinsurance: Coinsurance is like a deductible or copayment, except the patient pays a percentage of the cost, rather than a specific dollar amount.
Explanation of Benefits
Your insurer will normally send you an “Explanation of Benefits” when it processes a claim on your behalf. This document will be clearly labeled as an “Explanation of Benefits” and will prominently state that “This is Not a Bill.”
The Explanation of Benefits provides a summary of the charges that were submitted to the health insurer for payment. It will identify the billed amount, the amount that was paid on your behalf, and amounts (a deductible, copayment, or coinsurance) that are your responsibility to pay under your policy.
Because hospital and physician bills are normally separate, you will receive separate Explanations of Benefits for each type of service.