Jeffrey Wade
Billing for healthcare can be a confusing process, and it's important to understand what to expect financially when visiting a doctor. After a patient visits a doctor, the doctor's office typically submits a bill (also called a claim) to the patient's insurance company. This bill lists the services provided to the patient, and the insurance company uses this information to pay the doctor. The insurance company may then send the patient a report called an Explanation of Benefits (EOB), which details what the insurance company did when it received the doctor's bill. The EOB is not a bill, but it is important to be able to read and understand it to know what the insurance company is paying for, what it's not paying for, and why. After the insurance company pays the doctor, the patient may need to pay the doctor any remaining balance.
| Characteristics | Values |
|---|---|
| What to do if you receive a bill from the hospital or doctor | Check if the bill contains the words "insurance pending" or any other indication that the hospital/doctor has submitted the bill to the insurance company. If it does not, call the hospital/doctor and ask them to bill your insurance company. If they refuse, fill out the Blue Care Network Member Reimbursement Form and send it following the directions on the form. |
| How billing works | You contact a healthcare provider and provide basic information such as identification and insurance information. You then schedule an appointment. Next, you contact your insurance company to find out if these services are covered by your plan and get an estimate of how much the services will cost. After services are received, medical coders identify all services, prescriptions, and supplies received and update your records with the corresponding codes. The healthcare provider then creates and submits an insurance claim using these codes. A claims processor reviews the claim and decides whether to accept or reject it. If the claim is valid, insurance reimburses your healthcare provider by paying for some or all of the services. If rejected, the claims processor provides a detailed description of why the services are not covered. Your healthcare provider then bills you for the remaining balance. |
| How to avoid unexpected medical bills | Always ask what insurance will and will not pay for, and how much they'll pay for, before visiting a healthcare provider. If your healthcare provider is out of network, whatever the insurance company does not pay for will be billed to you. |
| What to do if your health insurance won't pay for a medical service | Contact your healthcare provider and insurance company to try to rectify any errors. Go through your insurance company's appeals process if necessary. If your insurance company required additional information that was not provided, follow up with your insurance company and healthcare provider to make sure all the necessary information is provided. If your healthcare provider is not in-network, verify that they are in your insurance plan's network. Contact a medical billing professional if there is a misunderstanding between your healthcare provider and insurance company. If your plan requires referrals or other pre-approvals to see a specialist, make sure to get a referral so that your future visits are covered. Ask your doctor to submit a "Medical Necessity" form on your behalf if your insurer denies your claim because the service wasn't medically necessary. Speak to a representative of your insurance company to understand why your care was not covered and try to appeal it if you feel an exception should be made. |
What You'll Learn
Understanding your medical bill
Medical billing can be confusing, but it's important to understand what to expect financially when you need to go to the doctor. Here's a step-by-step guide to understanding your medical bill:
Step 1: Contact a Healthcare Provider
When you need to see a doctor, the first step is to contact a healthcare provider and schedule an appointment. Before your appointment, be sure to provide basic information such as identification and insurance details. It's also important to ask about the services and supplies you'll receive and any associated charges. If you're unsure about what your insurance covers, contact your insurance company to find out.
Step 2: Receive Services
On the day of your appointment, you'll complete any necessary registration paperwork and consent forms. You'll also provide your insurance card and other relevant information. During your appointment, you'll receive medical services, which may include prescriptions, procedures, or tests.
Step 3: Receive a Bill
After your appointment, the healthcare provider will send you a bill. This bill will list the charges for the services you received. It's important to note that this bill is separate from the Explanation of Benefits (EOB) that you'll receive from your insurance company. The EOB is not a bill; it explains what services your insurance company covered and how much they paid.
Step 4: Review Your Bill
When you receive your bill, take time to review it carefully. Check that your personal information, such as your name, address, and insurance details, are correct. Verify the dates of service and the description of services, ensuring they match your records. Look out for any errors or discrepancies, such as duplicate charges or incorrect quantities. You can also compare the charges on your bill to the CPT (Current Procedural Terminology) codes and ICD (International Classification of Diseases) diagnostic codes to ensure they align with the services you received.
Step 5: Address Any Issues
If you identify any errors or have questions about your bill, don't hesitate to contact your healthcare provider's billing office. They can help clarify any charges and correct any mistakes. If needed, you can also reach out to your insurance company for further assistance. It's important to address any issues promptly to avoid potential issues with your credit score.
Step 6: Make Payment Arrangements
Once you understand your bill and have addressed any concerns, it's time to make payment arrangements. If you have insurance, they may cover some or all of the charges, depending on your plan. If you're responsible for any remaining balance, you can discuss payment options with the healthcare provider. They may offer payment plans or discounts for prompt payment.
Remember, it's always a good idea to keep a close eye on your medical bills and ask questions if something doesn't seem right. Don't be afraid to advocate for yourself and ensure you're only paying for the services you actually received.
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Contacting the hospital or doctor
Firstly, check the bill to ensure it is not marked as "insurance pending" or another indication that the hospital or doctor has already submitted the bill to your insurance company. If it is not marked as such, then you should call the hospital or doctor and ask them to bill your insurance company. You will need to provide them with the information on your insurance card or certificate. If they refuse to send the bill to your insurance company, or it is not possible for them to do so, then you will need to take further steps.
If your insurance company has not received the bill from the hospital or doctor, you may need to submit the bill to them yourself. Contact your insurance company to find out the correct procedure for doing this. They may require you to fill out a specific form, such as a Member Reimbursement Form, and include an itemized statement from the hospital or doctor. This statement should detail the services provided and the corresponding charges. Keep a copy of all documentation for your records.
Once your insurance company receives the bill, they will determine how much they will cover and how much you are responsible for. They will send you an Explanation of Benefits (EOB) outlining this information. It is important to understand that an EOB is not a bill. After your insurance company pays the hospital or doctor, you will then receive a bill for any remaining amount that you owe.
If you have already paid for your treatment, your insurance company should reimburse you for the services covered under your claim. Be sure to keep all documentation in case you need to follow up on the status of your claim or reimbursement.
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Contacting your insurance company
Understanding Your Coverage and Benefits:
Before contacting your insurance company, it is essential to have a clear understanding of your insurance plan and its benefits. Review your insurance policy to familiarize yourself with the terms, conditions, and coverage limits. Identify if your plan has any deductibles, copayments, or coinsurance requirements. Additionally, verify if there are any specific exclusions or restrictions on certain medical services or providers. Knowing these details will enable you to ask the right questions and effectively advocate for yourself during the billing process.
Verifying Coverage and Benefits:
Once you have a grasp of your insurance plan, it is recommended to contact your insurance company directly to verify coverage and benefits for the specific medical services you require. Provide them with detailed information about the healthcare provider, the nature of the treatment or procedure, and the associated costs. By doing so, you can confirm whether the services are covered by your plan and gain a better understanding of your financial responsibility.
Asking the Right Questions:
When speaking with a representative from your insurance company, ask clear and concise questions to obtain the information you need. Inquire about the extent of coverage for the services, including any applicable deductibles, copayments, or coinsurance amounts. Ask for clarification on any terms or conditions that you may not fully understand. Additionally, confirm if prior authorization or pre-certification is required for the services and if there are any specific guidelines or limitations you should be aware of.
Discussing Billing Discrepancies:
If you have received a bill that seems incorrect or inconsistent with your understanding of your coverage, don't hesitate to contact your insurance company. Inquire about any discrepancies and ask for a detailed explanation of the charges. Discuss the possibility of billing errors and request assistance in resolving them. Remember to remain persistent but polite throughout the process.
Keeping Records:
It is essential to maintain thorough records of your interactions with the insurance company. Keep a log of the dates and times of your calls, the names of the representatives you speak with, and the details of the discussions. Additionally, make copies of any relevant documents, bills, or correspondence. These records will be valuable if you need to refer back to specific details or escalate any issues.
Following Up:
Don't hesitate to follow up with your insurance company if you have further questions or concerns. If you are awaiting a response or resolution to a previous inquiry, be proactive in reaching out for updates. Following up demonstrates your engagement in the process and can help expedite the resolution of any outstanding issues.
Remember, your insurance company should be a valuable resource in navigating the complex world of medical billing. Don't hesitate to reach out and utilize their expertise to gain a better understanding of your coverage and financial responsibilities.
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Filling out the correct forms
Firstly, it is important to understand the sequence of events that occur when you receive medical services. Typically, after you visit a healthcare provider, their office will submit a claim, or a bill, to your insurance company. This claim outlines the services provided to you during your visit. The insurance company will then review the claim and determine how much they will cover and how much you, the patient, will need to pay. This breakdown of costs is outlined in a document called the Explanation of Benefits (EOB). The EOB is sent to both you and your healthcare provider, indicating how much the insurance company will pay the provider and how much you may owe for any remaining balance.
Now, let's discuss the forms you may need to fill out. When you receive medical services, your healthcare provider will usually ask for basic information, such as identification and insurance details. Ensure that you provide accurate and up-to-date insurance information to avoid any issues with billing. If you have multiple insurance plans, it is essential to determine the proper order for billing. Coordination of benefits rules apply in such cases, so contact your provider for guidance. Additionally, inquire about precertification or preauthorization requirements, as some insurance companies mandate prior authorization for specific medical services or medications.
In certain situations, you may need to take proactive steps to ensure proper billing. For instance, if you receive a bill from your healthcare provider or doctor before they have billed your insurance company, you should contact the provider and request that they bill your insurance. Provide them with your insurance information, including the details on your insurance card or certificate. If they refuse or are unable to do so, you may need to take additional steps, such as filling out a reimbursement form and submitting it to your insurance company. Keep in mind that different insurance companies may have specific forms and procedures for reimbursement claims, so be sure to follow their instructions carefully.
In some cases, your insurance company may deny a claim. If this occurs, it is crucial to understand the reason for the denial. Insurance companies are required to notify you in writing, explaining why your claim was denied and providing information about the appeals process. Common reasons for claim denials include errors in processing, lack of pre-approvals or referrals, the provider being out-of-network, or the service not being covered under your policy. If you believe there has been an error, contact both your healthcare provider and insurance company to rectify the issue. If necessary, initiate the appeals process as outlined by your insurance company.
Remember, it is always a good idea to review your insurance policy, understand your coverage, and stay organised by keeping records of your medical bills, EOBs, and other relevant documents. By being proactive and diligent, you can effectively navigate the medical billing process and ensure that you fill out the correct forms accurately.
Paying outstanding charges
Firstly, it is important to understand the reason for the outstanding charges. Contact both your healthcare provider and your insurance company to clarify the situation. Ask for detailed explanations of the charges and determine whether there have been any errors or misunderstandings. It is crucial to review your insurance plan to identify what is covered and what you are responsible for paying.
If the issue is due to incorrect billing, work with your healthcare provider to rectify the mistake. Ask for an itemized bill and carefully review the dates of service, descriptions of services, and corresponding charges. Compare this information with your insurance plan to identify any discrepancies. If you identify errors or overcharges, dispute these charges with your healthcare provider and request an updated bill.
In the case of denied or partially paid claims, reach out to your insurance company to understand the reason for the denial. Ask for specific details and initiate the appeals process if necessary. If the issue is due to a lack of pre-approval or referral, obtain the required referrals and resubmit the claim. If the claim is denied due to the provider being out-of-network, understand that you may be responsible for paying the balance.
If you have already paid for the treatment, you can request a reimbursement from your insurance company for the services covered under your claim. This can be done by submitting the necessary forms and providing supporting documentation. Alternatively, if you have not paid for the treatment, your insurance company may pay the healthcare provider directly.
Remember to keep detailed records of all communications, including dates, contact information, and the content of discussions. This will help you navigate the process and resolve any outstanding charges effectively.
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Frequently asked questions
First, check if the bill contains the words "insurance pending" or any other indication that the hospital/doctor has submitted the bill to the insurance company. If it does not, call the hospital/doctor and ask them to bill your insurance company. If they refuse or it is not possible, fill out a reimbursement form and send it to your insurance company.
A deductible is a fixed dollar amount that you need to pay within a defined period of time before your insurer will start to cover some of the costs for covered medical services. For example, if you have a $500 deductible, you will have to pay for your medical costs for non-preventative care until you have paid a total of $500. Once you reach that limit, your insurance company will begin to cover some of your medical costs for the rest of the year.
HMO stands for Health Maintenance Organization. An HMO is a group that contracts with medical facilities, physicians, employers, and occasionally individual patients to provide medical care to a group of individuals. PPO stands for Preferred Provider Organization. With a PPO, you must select a primary care physician (PCP) who is under contract with the PPO. If you choose a doctor not under contract, you pay more.
