Hi Friendos,
I am happy to report that since I wrote last week’s very personal newsletter, it looks like we have some rays of sunshine breaking through the clouds. More upcoming tests and doctor visits will provide additional information.
In the meantime, I have been giving myself a crash course on insurance and been learning a LOT. Is there any subject more boring, byzantine, and blood boiling than U.S. income taxes? Health insurance!
I will share my lessons learned with you in a detailed way so you can think about how to apply them in your own life. This has potential to save some serious money, which gets me excited. I hope you will report back on your own experiences and use the savings to improve your financial strength and otherwise take care of yourself.
Today’s insurance lesson: if you go to an in-network provider, they are probably NOT ALLOWED to make you pay for everything upfront. They can insist on getting your co-pay, but not the full cost of service or “your portion” that your insurance does not cover. Out-of-network is different – this is for in‑network.
In the last several years, every single time my husband has gone to Quest for bloodwork, they told him he had to pay prior outstanding bills (which we were fighting over with the insurance company) before they could draw blood. A couple months ago they tried to pull something similar with me. The conversation went like this:
Lab tech: “The cost for your bloodwork today is $128.”
Me: “I already called Cigna yesterday and they said each of these tests is fully covered by my insurance.”
Tech: “Well, this [one particular] test is showing at $128, so I need to charge you for that.”
Me: “Cigna told me that test is covered.”
Tech: “If the insurance does cover it after you pay, you will get a refund.”
Me: “I should not have to pay anything today because Cigna is covering all of these tests.”
Tech: “..” (proceeds to arrange supplies and then draw my blood)
I had actually called Cigna the day before because I knew this blood work was a bit more than “usual” and I wanted to understand my exposure. I had a copy of the doctor’s order for bloodwork that she had sent to Quest (you can always request copies of such orders), and the written order included test codes and diagnostic codes. I read each of these codes to the Cigna rep and they confirmed that each one was covered. I looked back in my phone log and see that the call lasted 12 minutes.
And indeed, Cigna did cover all my blood tests. How much time and effort would it have taken for me to get the $128 back from Quest if I’d caved that morning? Hard to say for sure, but why should I have to do it that way? When I got a mammogram in 2024, Lenox Hill Radiology charged me $573.30 for the follow up imaging I needed, but later, the explanation of benefits from insurance showed I should only have been charged $515.40, so it was an overcharge of $57.90. I called Lenox Hill Radiology and a few weeks later, they issued my refund. Fine. But they were definitely not going to do that without my phone call! And sometimes it takes people dozens of hours over many months to get refunds from providers. Sometimes people give up or don’t have enough time or gas in the tank to fight in the first place, and providers get away with stealing from us.
An episode of the excellent “Arm and a Leg” podcast enlightened me. The episode, released June 15, 2023, was called “Credit Card Please,” and in it, a health policy analyst shared this:
“Commercial insurance contracts generally prohibit providers from requiring payment upfront, except for the kind of co-pays that are spelled out in your insurance documents, like 30 bucks for an office visit.”
An insurance policy is a contract. For any medical insurance, dental insurance, or vision insurance, there is a policy contract that governs the terms of your insurance. This document is not a few-pages-long summary – we’re talking about something that is dozens of pages long. My current medical policy document is 127 pages, dental is 71 pages, and vision is 49 pages.
And…any provider that is in-network with your insurance, like any doctor or hospital or testing facility…they also have a contract with the insurance company. That is what it means to be in-network! To be under contract with the insurance company. They’ve agreed to charge specified prices and follow other terms outlined in their contract with the insurance company. Your provider has to follow all the rules of their contract. If they don’t, you can enlist your insurance company to enforce the terms.
Even if your insurance doesn’t cover the full cost of a provider service, after the insurance company initially processes the claim, you can fight with insurance to get it covered. I’ll discuss that in future newsletters. Also, you might be eligible for financial assistance or charity care. As the Consumer Financial Protection Bureau reported in 2023, “Many people who sign up for medical financing in doctor’s offices and hospitals may otherwise be eligible to receive financial assistance or charity care that medical providers may offer or otherwise be required to offer under federal, state, or local law.”
This coming week, my partner is scheduled for a minor dental procedure at an oral surgeon’s office. They told him it would cost $1,250 because none of it would be covered by his dental insurance. The office manager said, “You can appeal it but that can take months.” Peter said, “Well, I have cancer and I’m in touch with my insurance company every day.” HA! Indeed, we will be fighting for coverage on this as we are not yet tapped out on our annual coverage limit. I am also 100% sure the dentist’s office will ask for upfront payment at the appointment. I told my partner: they can’t make you pay upfront – don’t do it!
Yesterday I called our dental insurance company, which is Cigna, to get ammo for Peter’s appointment. Here are my notes from the call:
I called Cigna at ~6:55pm. I asked if a dentist who is in-network can make me pay for my portion of costs upfront. The rep said they can ask me to do that if it is their office policy. I said I understand, but can they insist I do that? I explained that I heard a health care reporter discussing this in an interview, that if a provider is in-network, they generally cannot make me do upfront payment.
After several minutes of her reviewing materials on her end, she said that if a dentist receives an overpayment, they must promptly return the excess amount.
But can they refuse to see me if I don’t pay upfront? No, they cannot say that they won’t treat me if I don’t pay them on the spot. Is there some document that states that? They can reference their dental office reference guide, which is a Cigna document.
Is that info in a certain section of the guide? She shows it is on p. 20, under “billing guidelines.” Is that document, the billing guidelines, something I, as a customer, could see? No, that is not a document that I as a customer would have access to.
If they are out of network, they can make me pay the full amount upfront.
Summary: if they are in-network, they cannot make me pay upfront before insurance has processed the claim, if they are out-of-network, they can.
Reference # for this call: 6913
Rep’s name: Ciera
I had to ask 3 times before she would straightforwardly say: No, they can’t make you pay upfront if they are in-network. But she did eventually confirm it to me since I kept repeating my question. Since I asked, she also clued me in to the name of a key document that is part of the dentist’s contract with Cigna, the “Dental Office Reference Guide.” If the office manager tries to bully Peter, he has a few arrows in his quiver.
The next time someone at an in-network provider says you have to pay for everything up front, you can say something like:
“Can you just bill me after the insurance figures out my share?”
Or:
“I’d like you to bill me after my insurance company processes the claim.”
It’s terrible that some of our providers choose to begin interactions with this kind of financial bullying. This week, I am especially in the mood to fight back.
A better world is possible!
-Stephanie
Frequently Taxed Questions 