Outpatient Physician's Guide To Navigating Insurance Billing: Strategies For Accuracy And Compliance

Billing insurance correctly as an outpatient physician is a meticulous process that requires a good understanding of medical billing and insurance terms. It is important to distinguish between in-network and out-of-network providers, as this distinction impacts billing and insurance coverage. In-network providers are those who participate in the patient's health plan, while out-of-network providers do not. Outpatient physicians need to be mindful of billing codes, such as CPT and HCPC codes, which help standardize billing and facilitate communication with insurance companies. Additionally, knowledge of insurance terminology, such as copayments, deductibles, and coinsurance, is essential for accurate billing. Outpatient physicians should also be aware of the patient's insurance coverage, including any limitations or exclusions, to ensure proper billing and avoid unexpected costs for the patient. Proper billing procedures include submitting bills to the patient's primary and secondary insurance carriers and providing itemized statements when necessary.

Understanding the bill/invoice/statement

The billing process can be complicated, but it's important to understand it to ensure you're not being overcharged for medical services. Here's a breakdown of the key components of a medical bill/invoice/statement:

• Statement Date: This is the date the healthcare provider printed the bill.
• Account Number: Your unique account number, which you'll need when contacting the billing office about your bill or balance.
• Service Date: The date(s) you received each medical service listed on the bill.
• Description: A short phrase explaining the service or supply provided.
• Charges: The full price of the services or supplies before insurance adjustments.
• Billed Charges: The total amount charged to you or your insurance provider.
• Adjustment: The amount the provider has agreed not to charge.
• Insurance Payments: The amount your insurance provider has already paid.
• Patient Payments: The amount you are responsible for paying.
• Balance/Amount Due: The outstanding amount owed to the healthcare provider.
• Payable to: The organization to which you should address cheque payments.

Additionally, you may see a "service code" listed on your bill. This is a standardised code, such as the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS), used by healthcare providers to identify the exact services and supplies provided during your appointment.

It's important to distinguish between a bill/invoice/statement and an Explanation of Benefits (EOB). While they may look similar, an EOB is not a bill. It is a document sent by your insurance company after they've processed a claim from your healthcare provider. The EOB explains what treatments and services your insurance company agreed to pay for, and what you are responsible for paying. It includes details such as the amount billed, the allowed amount, any co-payments, deductibles, or coinsurance due, and the total amount saved through your insurance plan.

When reviewing your bill, it's important to compare it to the EOB to ensure the information matches. If there are discrepancies or something you don't understand, contact your insurance company for clarification. It's also crucial to monitor your bills for errors, such as duplicate charges, incorrect dates, or charges for services you didn't receive. If you identify any issues, don't hesitate to contact your insurance company and/or healthcare provider to dispute the error.

Knowing what to do if you receive a bill from the hospital or doctor

Step 1: Check if the bill has been submitted to your insurance company

If you receive a bill from a hospital or doctor in the mail, first check if it contains the words "insurance pending" or some other indication that the bill has been submitted to your insurance company. If it has not been submitted, proceed to Step 2.

Step 2: Contact the hospital or doctor

Call the hospital or doctor and ask them to bill your insurance company. Provide them with the details from your insurance card or certificate. If they refuse or are unable to do this, proceed to Step 3.

Step 3: Fill out a reimbursement form

Fill out a reimbursement form and include an "itemized statement", which is either the bill you received or a statement provided by the hospital or doctor if you paid the bill yourself. Fax or mail the form following the provided directions. If you have already paid for your treatment, your insurance company or healthcare provider will reimburse you for the services covered under your claim. If you have not paid, the insurance company will pay the hospital or doctor directly. Be sure to make a copy of what you send for your records.

Other things to keep in mind:

• Check your bills for accuracy. Make sure the bill has your correct name, insurance information, and billing address, and that you received the treatments listed.
• Ask your provider for a clear explanation of any unclear items on the bill.
• If you don't have insurance or choose not to use it, your provider must give you a "good faith" estimate of how much your care will cost before you receive treatment. If the final bill is at least $400 more than the estimate, you may be able to dispute the charges.
• If you cannot afford the bill, talk to the medical care provider. Nonprofit hospitals are legally required to offer financial assistance programs, and other providers may be willing to arrange a payment plan.
• If you have insurance, you may also receive a form called an Explanation of Benefits (EOB) from your insurance company. This explains what is covered by your insurance, the amount paid and to whom, and any deductibles or coinsurance. The information on the EOB should match your hospital bill. If it does not, or if there is something you do not understand, contact your insurance company.
• Errors on your medical bill can cost you money, so it is worth checking the following carefully: dates and number of days; number errors, such as extra zeros; double charges for the same service, medicine, or supplies; medicine charges, especially if you brought your own medicines or were prescribed a generic drug; charges for routine supplies like gloves, gowns, or sheets; costs of reading tests or scans, which you should only be charged for once unless you got a second opinion; and cancelled work or medicines, which should not appear on your bill.
• If you had surgery or another procedure, you can use websites like Healthcare Bluebook or FAIR Health to find out if your hospital charged a fair price by entering the name of the procedure and your zip code to find an average or estimated price in your area. If the charge on your bill is higher than the fair price or higher than what other hospitals charge, you can use this information to ask for a lower fee.
• If you do not understand a charge on your bill, many hospitals have financial counsellors who can help explain it in clear language. If you find a mistake, ask the billing department to correct it and keep a record of the date and time you called, the name of the person you spoke to, and what you were told.
• If you are still not getting the help you need, consider hiring a medical billing advocate. Advocates charge an hourly fee or a percentage of the amount of money you save as a result of their review.

Knowing the difference between in-network and out-of-network providers

When it comes to billing insurance correctly as an outpatient physician, it's crucial to understand the difference between in-network and out-of-network providers. Here's a detailed overview:

In-Network Providers:

In-network providers have a contract with your health insurance plan and have agreed to provide healthcare services at a pre-negotiated, discounted rate. This relationship benefits you as the patient because you pay lower out-of-pocket costs when receiving treatment from an in-network doctor. In-network providers are part of your insurance plan's network of doctors, facilities, and pharmacies, and they must meet specific credentialing requirements to be included in this network.

Out-of-Network Providers:

Out-of-network providers, on the other hand, do not have a contract with your health insurance plan. Without this agreement, they can charge full price for their services, which is typically much higher than the discounted rate offered by in-network providers. When using an out-of-network provider, you may be responsible for paying the difference between the doctor's bill and what your insurance plan covers. Additionally, your share of costs, such as coinsurance (a percentage of covered charges), is usually higher with out-of-network providers.

How to Determine a Provider's Network Status:

It's important to verify a physician's network status before seeking treatment. You can do this by checking your insurance company's website or calling their customer service line. Additionally, your healthcare provider's website may list the insurance plans they participate in, allowing you to determine if they are in-network for your specific plan.

Benefits of Choosing In-Network Providers:

Selecting an in-network provider can help you save money on healthcare expenses. In some cases, your insurance plan may require you to use in-network providers, or it may not provide any coverage for non-emergency services received from out-of-network doctors.

When Out-of-Network Providers May Be Preferred:

While out-of-network providers generally result in higher costs, there are situations where using one may be preferable:

• Specialized Expertise: Out-of-network providers may possess unique skills or experience for specific conditions or procedures, ensuring you receive the best care.
• Geographic Accessibility: In rural or remote areas, there may be limited in-network options, making it more convenient to choose an out-of-network provider.
• Continuity of Care: You may prefer to continue seeing a healthcare provider with whom you have an established relationship, even if they are no longer in your network.

Knowing what to do when your insurance carrier has changed

When your insurance carrier changes, it's important to take several steps to ensure that you understand your new coverage and how it may impact your healthcare. Here are some detailed instructions to guide you through this process:

• Review your new insurance plan: Understand the terms and conditions of your new insurance policy. Pay close attention to the benefits covered, the network of providers, and any exclusions or limitations. Knowing what is and isn't covered will help you make informed decisions about your healthcare.
• Notify your healthcare providers: Inform your physicians, hospitals, and any other healthcare providers about the change in your insurance carrier. This is crucial, especially if your new insurance plan has different requirements or restrictions. By notifying them, you can ensure that they bill your new insurance carrier correctly and avoid unexpected charges.
• Understand provider networks: Familiarize yourself with the "in-network" and "out-of-network" providers under your new insurance plan. In-network providers have contracts with your insurance company and usually offer lower out-of-pocket costs. Out-of-network providers may charge higher rates, and your insurance may not cover the full amount. Check if your preferred physicians and hospitals are in-network to minimize unexpected expenses.
• Review your prescription coverage: Changes in insurance carriers may also impact your prescription coverage. Verify which medications are covered by your new plan and whether there are any restrictions or limitations. If you have ongoing prescriptions, check if they are still covered and determine if there are any alternative medications that may be more affordable under your new plan.
• Understand billing and payment processes: Learn how your new insurance carrier handles billing and payments. Understand your deductibles, co-insurance, and co-payments, as these will impact your out-of-pocket expenses. Additionally, familiarize yourself with the process of submitting claims and obtaining reimbursements to ensure a smooth experience when seeking healthcare services.
• Keep your insurance information up to date: Whenever your insurance carrier changes, update your insurance information with your healthcare providers. Provide them with your new insurance card and any other relevant details to ensure accurate billing and avoid delays in processing claims.
• Seek clarification if needed: If you have any questions or concerns about your new insurance plan, don't hesitate to contact your insurance carrier or a patient advocate. They can provide clarification on coverage, benefits, and any other details you need to maximize your insurance benefits and minimize unexpected costs.

Remember, it's important to stay informed about any changes to your insurance carrier and to take proactive steps to understand how those changes may impact your healthcare. By following these instructions, you can ensure that you are well-prepared to navigate the healthcare system with your new insurance coverage.

Knowing what to do if you don't have insurance

If you don't have insurance, there are still ways to get the healthcare you need. Here are some steps you can take to navigate the healthcare system without insurance:

• Check your eligibility for coverage: Even if you don't think you qualify for health insurance programs, it's worth looking into options such as Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). CHIP, in particular, is a federal program that provides funds to states to help families with children who don't qualify for Medicaid.
• Shop around for healthcare providers: Pricing for healthcare can vary greatly between providers, even in the same area. If you are paying out of pocket, be sure to ask about self-pay charges and discounts. Many providers offer special discounts for patients without insurance, especially if you're paying for care in full at the time of service.
• Compare rates and ask for estimates: Call different medical offices and health clinics to ask about their pricing. If you know the services you need, they should be able to provide a cost estimate. You can also ask for a good faith estimate in writing from your healthcare provider, which will give you an expected charge for the healthcare items and services you require.
• Look into community health clinics: Many states and counties have free clinics or community health centers that provide low-cost or free medical services to people without insurance. These clinics are often equipped to handle a range of medical needs and conditions.
• Choose urgent care for non-life-threatening issues: If you have a non-life-threatening medical issue, consider visiting an urgent care center instead of the emergency room. Urgent care centers are usually much cheaper than the ER and can treat a range of issues such as urinary tract infections, sprains, fractures, and lacerations.
• Be upfront about your financial situation: Explain your financial situation to your healthcare provider and their administrative staff. Ask about payment plans, sliding scale payments, and other financial assistance options. Remember that medical bills are often negotiable, and you can always try to get your bill reduced if it's higher than expected.
• Know your rights: Familiarize yourself with relevant laws and acts, such as the No Surprises Act, which protects you from unexpected out-of-network bills in certain situations. Understanding your rights as a patient will help you navigate the healthcare system and avoid unexpected charges.

Frequently asked questions