Consumer Resources


  • Be an Informed Patient
    • Understand Your Medical Condition and the Proposed Treatment
      • Being an informed patient includes learning about your medical condition, the medical procedure or treatment that has been recommended, and suggestions on next steps.

    • Places To Start
      • HealthFinder®  (available in Spanish)

        Developed by the U.S. Department of Health and Human Services, this website provides access to carefully selected information from more than 1,500 health-related organizations. It provides a description of the condition, and information on causes, risk factors, symptoms, diagnosis, treatment and prevention.

      • National Library of Medicine

        Includes links to health-related sites, resources and databases that can be used to research health conditions and diseases.

      • How to Find Reliable Health Information

        Downloadable brochure from the Joint Commission that provides consumers with a list of sites recommended by the Medical Library Association and the Department of Health and Human Services.


  • Coverage
    • Understand Your Coverage and How Much You Will Be Expected to Pay
      • Hospitals will often accept amounts less than their billed charge as payment in full. However, patients should expect to share the cost of an inpatient stay or other hospital service.

    • What is My Coverage?
      • Many health care consumers don't take the time to understand their health insurance coverage before they incur medical expenses. The time to address any confusion is now, not when you are facing a stressful medical situation and may have to make decisions quickly.

    • If You Do Not Have Health Insurance
      • You should investigate your options and eligibility for coverage at the U.S. Government official health care site:
        www.healthcare.gov

        Hospitals also have charity care policies that offer partial or total fee reductions, or payment plans, to patients who have a financial need. However, hospitals expect that patients will cooperate in the eligibility determination process.

    • If You Have Health Insurance
      • NCQA maintains an up-to-date list of insurers in Wisconsin.

        Contact your insurer.

        Explain what is to be done, when it will be done, and by whom (hospital/physician).
        Confirm the provider will be covered, and if the provider is in-network or out-of-network (this will affect coverage).
        Confirm that the procedure will be covered.
        Ask if there are any other 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.

        The PricePoint web site provides information on billed charges for all types of inpatient and selected outpatient services. However, lower hospital charges may not necessarily mean that you will pay less out of your pocket. That is why it is important for you to contact your insurer BEFORE the procedure.

        Many commercial insurance companies or employer self-funded plans require enrollees to seek care exclusively from a specific group of hospitals and physicians under contract with the insurer or employer in order for the the service to be covered. The group of hospitals and physicians is often called a "network".

        Other insurers and employers will cover the services of hospitals/physicians that are NOT in the network, but require the patient to pay a higher percentage of the cost for using those hospitals/physicians.

        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 to provide the names of the anesthesiologists, pathologists and radiologists in the network who provide services at the hospital. These are types of physicians who may provide services related to your inpatient stay or other hospital service, but it's possible you may never interact personally with them. As with surgeons, they are often not employees of a hospital and therefore their services will probably be billed separately. If they are not part of the insurer's network, you may be responsible for a larger portion of their fee, or the entire fee.

        Information on some professional fees can be found in PricePoint's Professional Services report.

  • Quality
  • Payment
    • Understand How Payment Works
      • It is important to remember that although physicians provide services at hospitals, 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 the "professional" (physician charges) and the "facility" (hospital charges) associated with your inpatient stay or other hospital service.

        Information on some professional fees can be found in PricePoint's Professional Services report.

    • Out-of-Pocket Costs
      • Most types of coverage do not pay the entire cost of health care services. They usually require the patient to contribute to the cost of the services in one or more of the following ways:

        Deductible A total 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 preventative or well-child care) are not subject to the deductible. Sometimes deductibles apply only to specific types of services, like hospital inpatient care or durable medical equipment.

        Copayment A per-service deductible. Health plans will often require a copayment for physician office visits or prescription drugs.

        Coinsurance 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". Bills for amounts you may owe are sent separately.

        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 Explanation of Benefits for each type of service.

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