Medical Bills Vs. What You Owe Are You Paying Or Being Billed More Than You Owe

So IF you are the person that is never sick, you might have two maybe three doctor bills a year. (Lucky you! I would really like to be in your shoes!) If not, well it is time to grab your calculator, your checkbook and the medical bills that you have shoved in that shoe box that is out of sight and pay them off. But are you paying what you really owe and not just what the bill is saying you owe? This can be overwhelming if you just went through a surgery, major illness or even an emergency visit to the hospital. I’m going to give you the basic lesson of making sure you are paying only what you owe and not just what the medical bill says you owe.

If you read part one, you might remember that I warned you to save the information when you enrolled in your health plans because you would need it later. Well, it’s later! So grab that packet of information and let’s get started. Go through your enrollment packet and make sure that you marked the plan you chose for Medical with a highlighter, big star or something so you don’t confuse yourself later. I’m going to take you through paying only your medical bills as dental, vision and prescription benefits are sometimes different.

If you have a HMO or POS plan using your HMO benefits, then normally the medical provider of service (your doctor, hospital or other entity) will bill your insurance company. If you have a PPO thought or are using your POS PPO option then you may be responsible for filing your bill. You must check with the medical provider of service before you walk out the door, especially if you have paid for the services in full. If you paid for the services in full you need a copy of the itemized bill and a receipt showing how you made payment and the amount you paid. You can always ask for an itemized statement before you leave any medical establishment. The itemized statement may be different from the bill you normally score in the mail. The Itemized statement is a complete breakdown of services that were provided with billing codes (normally five digits long but sometime the billing codes may have letters with numbers), a description of each service that describes the billing code, the charge for each code, as well as the date the service was provided, the name of the medical supplier and the patient’s name. Some insurance companies want this billing on a standard billing form. You will need to check with your insurance company to peek what an acceptable form of billing is for you and if you are required to submit the itemized bill with a member claim form. Make sure to keep copies of receipts, itemized bills and even your member claim forms when you submit your claim to the insurance company. Don’t send the original documents unless your insurance company specifically asks for the original documents. Copies are usually okay. If you find that your first submission was never received; send your claim to the insurance company again marked in ample letters “second request”. Just make sure that you are not writing over anything that the computer will need to read to process your claim.

Filing a medical bill for payment to the insurance company is also known as filing a claim. If you accept a bill from anyone who provided medical services to you then you should also get an Explanation of Benefits letter (also know as EOB) from the insurance company once payment has been made to that provider of medical service. The Explanation of Benefits letter is a break down of information so that you will know of who sent in a bill (the name of the doctor, hospital or other provider of medical service), the name of the patient, the date the services were provided, a smash down of the services provided from the charge of the office visit right down to the last Band-Aid (this could include a code that is usually five digits long followed by a description of what that code means or just a description of the service and charges), what the discount was for each billed item (remember that is why you are seeing a contracted doctor so if you are using your out of network PPO benefits this is were you will see what the difference is between what is billed and the reasonable rate), what was paid to the provider of medical service and your responsibility. Some Explanation of Benefit letters have more information than this but some have only this basic information. The Explanation of Benefits is not a bill! It is an explanation of what the insurance company has paid on your behalf. Be aware that 95% of all of these calculations were done by a computer and the processing of the bill may never have been touched by a human. Computer errors happen so you do need to make positive you know what you really are responsible for as far as what you owe!

Acquire the time to learn to read your Explanation of Benefits letters. Some of these letters have nice miniature charts on them that tell you how to read them attached while others don’t. Hey, it’s okay if you have no idea what you are looking at. Call the customer service phone number that you have on the letter. You say there is no phone number on your letter? Then call the customer service number on your member ID card. Ask the representative to go over the Explanation of Benefits with you and make notes. Make sure you read all of the small print. Sometimes a puny number, letter or sign will appear and you may have to go to the bottom of the Explanation of Benefits letter to find out what that little caption means. It can form all the difference in what may be held as your responsibility for payment even when it shows zeros in the patient responsibility line!

So now it is time to play match up. You will need to match your doctor’s bill to the Explanation of Benefits. But what if you have a bill and no matching Explanation of Benefits? Call your insurance company to perform certain that your medical bill was sent in for payment. With an HMO or POS using your HMO benefits, the doctor, hospital or other contracted provider of medical service is responsible for submitting a bill to the insurance company. The insurance company is responsible for making payments before YOU make all final payments on contracted providers. This is not the case with PPO plans if you used your out of network benefits. You can be held responsible for full payment up front and can expect to get reimbursed back from the insurance company.

Because 99% of all claims (Bills) are sent in by a contracted doctor, hospital or other provider of medical service, you should not receive a final bill, only a notice or initial bill that shows what was billed to the insurance company. Set Aside this initial bill someplace safe because it is usually an itemized statement (the rupture down of the description of services with the five digit billing code and the charge of each code). It may save you a trip to the doctor’s office or hospital billing department when you seem to be floating in limbo because the bill was never received. Many providers of medical service send their bills electronically to the insurance company. This is supposed to reduce paper waste but if you sometimes have pain getting your Internet plot to load up at home, imagine that on a large scale! There is a tracking process in place at the provider of medical service waste. If they can’t produce the evidence that the claim was submitted with in a time frame that was agreed upon by their contract with the insurance company or plot insurance guidelines, then the medical provider will not be paid. That’s right folks! If it is a medical provider who has signed a contracted with your insurance company they will have to eat that cost of what the insurance should have paid and can only bill you for your responsible portion like your co-payment or co-insurance. (Now you didn’t judge that you, as the patient, would regain out of paying what you owe did you? But check with your insurance company because sometime you may not have to pay but usually you responsible for your part.)

You should make sure that your co-payment is right for the service that was provided. If you have a one co-payment for your primary care physician that is different from you specialist physician co-payment then makes sure your statement has the apt co-payment. If your plan has a co-insurance portion, compose sure that if you are responsible for say 20% of an office visit that you are paying the 20% after the discount was taken and that the calculation was not done before the discount. Use your calculator to make sure everything balances. (And you concept you would never exercise that pesky math once you left high school!) If it is wrong, call the insurance company and go over your math and your benefits. Someone calculated wrong and you need to know if it was the insurance company or you. Get the name of the person you spoke with and a call back number if that representative has one. Also ask if there is a reference number for your call. Chances are that if you have to call back about this spot you can find out quickly what was done to resolve your quandary.

Yes, Yes, Yes…You paid your co-payment or co-insurance before you even saw the doctor, had surgery, or received medical services. Remember, this is not a bill! This is a statement of what you should have paid before you saw the doctor. If you paid your co-payment or co-insurance then you have nothing to pain about. If not, you now know what the doctor or medical provider can bill you. If you overpaid your bill then you now have proof to get a refund. And that leads us to the next little quirk: What if the bill doesn’t match your Explanation of Benefits statement? Call that provider of medical service up and find out why you are being billed more than your insurance statement. It could be anything from your account hasn’t been updated to a debate that the insurance company paid the bill incorrectly. The medical provider should be fighting it out with the insurance company when it comes to “contract disputes” (as long as it is a provider of service that has a contract with the insurance company) and you should not accept caught in the middle. (Yeah right, like that will never happen!) Call the insurance company and speak with a representative about the problem. The insurance company will make contact with the medical provider to work out the quandary only if they know a plight has involved you. If you have an command with a medical provider that is not contracted, check with the insurance company to scrutinize what your responsibility is for payment to the medical provider. If the insurance company doesn’t know there is a pickle, they can’t do anything to fix it.

The inevitable happened; you have a bill from a medical provider that doesn’t have a contract with the insurance company! You followed all the rules. How did this happen? Yeah there is a flaw in every system. The most popular occurrence is when you go to the hospital. We know that lots of doctors work for the hospital or do they? Well, the doctors don’t really work for the hospital it is more like subcontractor work. The emergency room physician, radiologist, anesthesiologist and pathologist must have qualified doctors to work these areas. The hospital works out an plot with usually a group of doctors to lease their services to fill the void. The hospital provides the workspace, equipment, supplies and patients while only billing for these specific items. These specialized doctors provide medical care and bill separately from the hospital. They are not hospital employees so these doctors do not fall under the hospital’s contract with the insurance company. But don’t despair, if you are in a hospital that has a contract with the insurance company, the insurance company will not penalize you. But they try to get a discount when they can. If these specific doctors do not want to give the insurance company a discount, they are not obligated to do so. You will need to call the insurance company if the doctor’s billing company won’t, and make sure that you let the representative you speak with know what has happen. The insurance company should make everything lawful by paying the bill in full only for HMO members or POS members that used their HMO plan and were referred to the hospital by their primary care physician. If you chose the PPO plan or have the POS opinion and went to an in network hospital, well you get the short end of the deal. The bill should be paid at the higher benefit level if you went to an in network hospital. Otherwise all bets are off and your claim will be paid at the out of network benefits. You will still be responsible for the deductible and the in network co-insurance will apply if you went to an in network hospital but it falls under the reasonable rates just like the normal out of network benefits. You are left paying any amount that the insurance payment didn’t cover. This is accurate for each of the doctors mentioned earlier (This is one of the diminutive facts about the PPO plan that the average person doesn’t know about!)

Out of network is out of network and there is no other way to get around that fact. If you went without you insurance company’s blessing you will be responsible for the charges on an HMO Belief. POS and PPO plans will be penalized with the out of network deductible and co-insurance amount.

If you believe that you have been penalized unfairly, can you complain? Well of course! There is always a fragment in your notion booklet about appeals, complaints and grievances. Read that fragment and follow the guidelines. Most of the time you will have to file you complaint in writing showing the proof of why you believe you are right and the insurance company is wrong. When you get a letter back with the outcome and you are smooth not happy continue on with your complaint, appeal or grievance based on the information in the letter you received and the guidelines in your plan booklet. As a member you have more level of appeal available to you than the provider of service. If you get to the end of whom you can appeal to at the insurance company and even the State Department of Insurance uphold the denial of payment on your claim, well, you have reached the end of the line. You can try taking it to your employer but if the last entity was the State Department of Insurance then your employer will probably side with the State. You might just have to chalk that loss up to a learning experience.

There are no posts related to Medical Bills Vs. What You Owe Are You Paying Or Being Billed More Than You Owe.

No tags for this post.

Related Posts

• No Related Posts.