Understanding The 'Do Not Bill Insurance' Form: Protecting Patient Privacy And Financial Responsibility

A 'do not bill insurance' form is used when a patient does not want to use their health insurance to cover the cost of a medical service. This may be because they do not have insurance, or they choose not to use it for a particular service. In these cases, the patient can request a good faith estimate of the cost of their care upfront before their visit. This is to protect them from surprise medical bills.

Understanding your insurance coverage and what is not covered

Insurance is a way to manage your financial risks and protect yourself and your family against unexpected financial costs and resulting debts. Insurance coverage is the amount of risk, liability, or potential loss that is protected by insurance. The most common types of insurance coverage include life, health, auto, and homeowners insurance.

Life Insurance Coverage

Life insurance coverage provides beneficiaries with a sum of money upon the death of the insured individual. There are two main types of life insurance: term life insurance and permanent life insurance. Term life insurance covers you for a specific period, such as 10, 20, or 30 years, while permanent life insurance covers you for your whole life.

Health Insurance Coverage

Health insurance coverage can help individuals avoid paying the full costs of medical expenses incurred when they require medical attention. Depending on the type of coverage, it can protect against routine and emergency medical care costs, as well as vision and dental services. It's important to understand what your health insurance plan covers and what it doesn't, as most health insurance plans do not cover fertility treatments or weight loss surgery.

Auto Insurance Coverage

Auto insurance is used to protect individuals from financial losses associated with medical expenses and repair costs due to a car accident. Basic auto insurance policies typically include bodily injury liability, personal injury protection, property damage liability, collision, and comprehensive coverage. However, auto insurance usually does not cover damage to your own car, unless you purchase additional coverage.

Homeowner's Insurance Coverage

Homeowner's insurance protects you from financial losses related to your home, including repairs, maintenance, and replacement of damaged items inside your home. Depending on the type of coverage, it can also cover losses such as clothing, furniture, and electronic appliances. Homeowner's insurance typically does not cover damage caused by floods or earthquakes, and you may need to purchase separate coverage for these scenarios.

Understanding What Is Not Covered

It's important to note that insurance policies have exclusions and limitations, and not all losses will be covered. Exclusions are specific events or items that are not covered by the insurance policy, such as pre-existing conditions or certain medical procedures. Limitations refer to caps or maximum amounts that the insurance company will pay for a covered loss. It's crucial to carefully review your insurance policy to understand what is and isn't covered, as well as any applicable deductibles or copayments.

Knowing your rights against surprise medical bills

Surprise medical bills are unexpected bills from an out-of-network provider or facility. These bills are the result of a billing disagreement between insurers and out-of-network providers. Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or facility, your health plan may not have covered the entire out-of-network cost. This could leave you with higher costs than if you had received care from an in-network provider or facility.

The No Surprises Act is a federal law that came into effect on January 1, 2022, and protects people covered under group and individual health plans from receiving surprise medical bills. It establishes an independent dispute resolution process for payment disputes between plans and providers and provides new dispute resolution opportunities for the uninsured and self-pay individuals.

If you have health insurance:

• You are protected from surprise bills when you receive emergency care and are required to pay cost-sharing for these services, like co-pays, based on in-network rates, even when care is received without prior authorization.
• You are protected from surprise bills from certain out-of-network providers if you go to an in-network hospital for a procedure. This means cost-sharing for certain additional services during your visit will generally be based on in-network rates.
• You are protected from balance billing for emergency services as well as for certain services at an in-network hospital or ambulatory surgical center.
• You are protected from balance billing for certain services at an in-network health care facility. When you get services from an in-network hospital or ambulatory surgical center, some members of your care team may be out-of-network providers. In these cases, the most those providers can bill is your plan's in-network cost-sharing amount.
• Your health plan will generally provide the following protections:
• Cover emergency services without requiring approval in advance (prior authorization)
• Cover emergency services by out-of-network providers
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility
• Count the amount you pay for emergency or out-of-network services toward your deductible and out-of-pocket maximum

If you don't have health insurance or choose to pay for care on your own:

• In most cases, you will receive a good faith estimate of how much your care will cost before you receive it.
• If you are charged more than your good faith estimate, you may be able to dispute the charges. For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of the date on your bill.

How to dispute a medical bill

Disputing a medical bill can be a confusing and frustrating process. Here is a step-by-step guide to help you navigate the process:

• Check your bill for accuracy: Review your medical bills closely to ensure that the items listed are accurate and reflect the treatments you received. Verify that the bill has your correct name, insurance information, and billing address. If there are any discrepancies or unclear charges, contact your medical provider for a plain language explanation.
• Understand your insurance coverage: Carefully review your insurance plan to determine what charges are covered and what your out-of-pocket responsibilities are. Understand the difference between in-network and out-of-network providers, as this can significantly impact your costs. Contact your insurance company if you have any questions about your coverage.
• Identify potential errors or discrepancies: Compare your bill against your insurance plan to identify any charges that should be covered by your insurance or your medical provider. Look for double charges, coding mistakes, and incorrect calculations. Wait for the Explanation of Benefits (EOB) report from your insurance company, which explains what they have covered for a specific date and healthcare visit. Ensure that your bill reflects any benefits payments.
• Contact your medical provider: If you identify any mistakes or discrepancies, contact your medical provider and explain the issue. Ask them to review and correct any errors. If they believe the charges are accurate, request a letter explaining their position. Keep detailed records of all communications, including the names of individuals you speak with, dates, and summaries of conversations.
• File an appeal with your insurance company: If you believe your insurance company should be covering certain charges, file an appeal. This process usually has strict time limits, so act quickly. Include relevant documentation such as medical records and letters from your medical provider supporting your position. Be prepared for delays and continue to keep detailed records of all communications.
• Dispute the bill with the collection agency: If the bill is sent to a collection agency during the appeal process, notify the agency in writing within 30 days that you are disputing the bill. Request them to refrain from sending the matter to court while the investigation is ongoing. Communicate with your medical provider about the dispute and provide them with information about your insurance status and provider.
• Work with a medical advocate: If your appeal is denied, consider seeking assistance from a medical advocacy agency. These agencies work with clients for free and can help negotiate a solution with your insurance company or medical provider. Contact local community resources or disease organizations to find medical advocates.
• Negotiate with your medical provider: If all else fails and you are still responsible for the bill, try negotiating directly with your medical provider. Ask for a discount and provide proof of financial hardship, such as tax records or bank statements. Many providers are willing to offer discounts or financial assistance programs to help patients.
• Prevent future issues: To avoid future problems, take the time to thoroughly review and understand your insurance plan before seeking medical services. Know your requirements, coverages, and the network of providers included in your plan. This proactive approach can help minimize unexpected costs and disputes.

The process of billing insurance companies for medical claims

Patient Registration:

The billing process begins with patient registration, where basic patient data is collected, including demographic information, contact details, health insurance details, and medical history.

Insurance Verification:

The patient's insurance information is verified by contacting their insurer to confirm coverage, benefits, deductibles, copays, and other relevant details. If there is secondary insurance, this is also noted.

Patient Encounter:

During the patient's visit, physicians document the encounter by recording treatments, diagnoses, prescriptions, and services provided. This information is crucial for billing and coding purposes.

Medical Coding:

Medical coders review the clinical documentation and assign standardized codes (ICD-10, CPT, and HCPCS) to indicate diagnoses, procedures, and services performed. These codes are used by insurers to assess reimbursement based on the patient's health plan.

Charge Entry:

Charges for the services provided are entered into the practice management system, along with any payments made by the patient. This information is used to create a "superbill," which includes provider details, patient information, medical codes, and insurance authorization.

Claim Scrubbing:

Before submission, claims are "scrubbed" to check for accuracy and ensure that the procedures, diagnosis codes, patient data, and other information are correct. This step helps to minimize the risk of claim denial or rejection.

Claim Submission:

Claims are submitted on specific forms (CMS-1500 for physician practices, CMS-1450 or UB-04 for hospitals, and other forms for private payers and Medicaid). Claims are typically submitted electronically to the insurance company, either directly or through a third-party vendor or clearinghouse.

Adjudication:

The insurance company evaluates the claim to determine its validity and reimbursement amount. They may accept, reject, or deny the claim. If accepted, they will pay the provider accordingly. If rejected or denied, the provider receives a notification with details and can correct and resubmit the claim or initiate an appeals process.

Patient Statement Preparation:

After claim reimbursement, the patient is billed for any procedures not covered by insurance. If the patient received care from an out-of-network provider, the No Surprises Act protects them from unexpected balance billing.

Accounts Receivable Follow-up:

The final phase involves collecting patient payments. Medical billers initiate processes to ensure payment from patients, including sending statements and following up on unpaid balances.

Tips for preparing a medical billing form

The medical billing process can be tedious, but it becomes significantly easier with the right preparation. Here are some tips for preparing a medical billing form:

• Check with each insurance payer to determine what data is required. Different insurance providers may have different requirements for information on claim forms, so it's important to check beforehand to ensure you have all the necessary details.
• Ensure that all data is entered accurately and in the correct fields. Double-check that all information, especially personal and insurance details, is correct to avoid any delays or issues with the claim.
• Use the correct diagnosis and procedure codes. Diagnosis codes should be ICD-10 or ICD-11, while procedure codes should be CPT/HCPCS. Modifiers should be used when required.
• Include National Provider Identifier (NPI) information where indicated. This helps identify the healthcare provider and ensures proper billing and reimbursement.
• Provide detailed service information, including dates, location, and a description of the services provided, along with the corresponding charge amounts.
• Use the patient's full legal name and ensure that the name matches the name on the insurance card.
• Indicate the patient's insurance information, including the insurance company, policy number, and group number. This is crucial for reimbursement.
• Obtain the patient's signature. Most medical billing forms require the patient's signature to authorise the claim and release of information.
• Complete a separate form for each service provider involved in the patient's care. For example, if the patient was treated by a physician and a specialist, two separate forms would be needed.
• Keep accurate records of all billing forms, payments, and reimbursements. This helps with tracking and managing patient accounts.
• Use a claim scrubber to check for errors before submitting the form. This can help identify any mistakes or missing information and reduce the risk of claim rejection.

Frequently asked questions