Orlando Harmon
Understanding your medical bills and how to get your insurance company to pay them can be a complicated process. It is the insured's responsibility to understand the benefits of their health plan and how it works. Depending on the specific circumstances, the patient may be responsible for paying their medical bills, or the insurance company may be required to pay them. In some cases, the responsible party in an accident may be liable for covering the medical expenses of the patient. There are also government programs that can help pay for medical care, such as Medicare, Medicaid, CHIP, the ACA, and COBRA. Additionally, charity care programs may assist with remaining costs after insurance or Medicaid payments have been applied.
How to get medical bills for insurance company
| Characteristics | Values |
|---|---|
| Understanding your medical bills | Review your Explanation of Benefits (EOB) and billing statements carefully. Contact your doctor's office if the dates of service and description of services on your EOB and billing statement aren't the same or do not match your records. |
| Contact your insurance company | Reach out to your insurance company if you have questions about why they did not cover something or about the amount you have to pay. |
| Outstanding bills | If your insurance company has not paid your doctor after 60 days, contact them. If the insurance company refuses to pay, you may need to pursue legal action to make them take responsibility. |
| Additional financial support | Government programs like Medicare, Medicaid, CHIP, the ACA, and COBRA can help with health expenses. Charity care programs may assist with remaining costs after insurance or Medicaid payments. |
| Debt management | You may be able to get help with a debt management plan, which involves a payment schedule that a credit counselor develops. |
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What You'll Learn
Understanding your medical bills
Personal Information
First, check that your name, address, and other personal information are correct. This may seem obvious, but it's important to ensure that the bill is intended for you and that there is no mix-up with another patient.
Provider or Facility Details
Make sure you understand which provider or facility is billing you. The bill should include the name and address of the provider or facility. If you don't recognize the name or don't see the expected medical practice on the bill, contact the number provided to clarify.
Account Number
Each provider or facility will assign you a unique account number. This number is important when making payments to ensure that you receive credit for your payment. You may also need this number if you have any billing inquiries.
Description of Services
Review the listed services or supplies and ensure they match the dates and treatments you received. Descriptions can sometimes be vague, contain abbreviations, or include complex medical terminology or billing codes. If you're unsure about any of the listed items, don't hesitate to contact your provider or facility for clarification.
Costs of Services
This section will outline the charges for the services and/or items you received. You may see multiple amounts, including the total charges, which represent the full price of the services and/or items. Another important amount to look for is the "allowed amount," which is the maximum amount that your insurance plan will pay for a covered health care service. This amount may also be referred to as the "eligible expense," "payment allowance," or "negotiated rate." If your provider is out of network and charges exceed this allowed amount, you may be responsible for paying the difference.
Explanation of Benefits (EoB)
If you have health insurance, you should receive an Explanation of Benefits from your health plan before getting a bill from your provider. The EoB will outline the costs of your care, including the services received, the dates, the amount your health plan will cover, and any remaining amount you owe. It's important to compare the EoB with your medical bill to ensure they match and to identify any discrepancies.
Payment Options and Assistance
If you're facing challenges in paying your medical bills, there are options available. These include government programs like Medicare, Medicaid, CHIP, the ACA, and COBRA, which can provide support with health expenses. Additionally, you may explore debt management plans or seek assistance from state social services agencies, which can offer referrals to local health centers and organizations that may be able to help.
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Knowing what your insurance covers
Contact Your Insurance Provider
If you have any questions about what your plan covers, contact your insurance company. Member Services representatives are there to answer your questions. They can tell you whether a doctor, prescription, or service is covered, plus how much your insurance will pay. You can call the phone number on the back of your health insurance card to ask about your coverage. You can also ask about the rate of coverage, your co-pay and/or coinsurance, and the number of appointments or days of treatment covered per year.
Review Your Plan's Formulary
If your plan includes prescription drug coverage, it will have a list of the medicines it covers, also known as a formulary or drug list. Review the list to ensure the prescriptions you need are included and if they need any special approvals (pre-authorizations). Some plans also offer a calculator tool to help you find the lowest prices on prescriptions from specific pharmacies or in different quantities.
Check Your Plan's Website
You can also check your health insurance plan’s website to see the benefits they offer. You may have to log in to your account to do this. When you compare plans in the Marketplace, you'll see the specific benefits each plan offers, and you can refer to a glossary for more details.
Diagnosis and CPT Codes
If you have a provider, you can ask them what your diagnosis code is for insurance purposes. Diagnosis codes are a combination of numbers and letters used by treatment providers and insurance companies to identify covered benefits, claims, and payments. When you are seeking services, you can call your insurance company and provide the CPT code to ask if it will be covered. This will allow them to answer definitively, as they will likely just need to input the code into their system.
Understand Common Insurance Terms
Understanding common insurance terms can help you better navigate your policy. For example, "medical necessity" is a term used to describe treatment that your provider feels is necessary for you to receive, but insurance companies may not agree and can deny coverage. Another term is "co-insurance," which is the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. This is usually expressed as a percentage, such as you paying 20% if the health insurance company pays 80%.
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What to do if your insurance company refuses to pay
When an insurance company denies a claim, it's usually because they've decided that the claim isn't covered under your policy. Here are some steps you can take if your insurance company refuses to pay:
Understand the reason for the denial
Call your insurer to understand why your claim was denied and verify if there were any errors in the filing process. Many denials are a result of administrative errors.
Review your policy
Thoroughly review your insurance policy to understand what is covered and what needs to be done to file a claim. This will help you determine if your claim should be covered and if there are any steps you may have missed in the filing process.
Start the appeal process
If you still believe that the insurance company should pay out, contact them again to understand how to initiate the appeal process. This may involve providing additional documentation or evidence to support your claim.
Contact a state regulator or ombudsman
If your appeals are denied, you can seek assistance from a state regulator or ombudsman. They can guide you through the process and provide information on your rights and options.
Consult a lawyer
If you feel that your insurance company is acting in bad faith or denying your valid claim, consider consulting a lawyer. A lawyer can help compile and submit the necessary documents and apply pressure on the insurance company to settle.
File a lawsuit
As a last resort, if all other options have been exhausted, you may need to take legal action against the insurance company by filing a lawsuit. This should be done within the statute of limitations for filing insurance claims in your state.
It's important to stay calm and patient throughout the process, documenting all your interactions and communications with the insurance company. Additionally, you can refer to studies and ratings of individual insurance providers to make an informed decision if you need to switch to a new provider.
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Getting help with medical bills
Medical bills can be expensive, but there are several options for getting financial assistance to help reduce your costs. Firstly, you should determine whether you qualify for any government programs that can help with health expenses. These include Medicare, Medicaid, CHIP, the ACA, and COBRA. These programs can provide coverage for medical, vision, and dental care, and your eligibility is based on factors such as income, age, employment status, and health issues. If you already have insurance, certain programs may still provide additional support. For example, there are Medicare Savings Programs that can assist with Part A and Part B premiums, deductibles, coinsurance, and copayments.
If you are uninsured or your current insurance plan does not cover the treatments or medications you need, you may qualify for financial assistance through a debt management plan. This involves working with a credit counselor to develop a payment schedule based on your financial situation, which can help make your medical debt more manageable. Additionally, some hospitals offer bill forgiveness or financial assistance based on income. You can inquire about these programs by contacting the hospital's billing department or searching for their financial aid policy online.
Pharmaceutical companies may also be able to provide assistance. You can contact them directly to inquire about low-cost options, samples, or discounts. Generic drugs can also help lower your prescription drug costs. State social services agencies are another resource, as they provide direct assistance and referrals to local health centers and organizations that can help with medical expenses.
Finally, charity care programs may be able to assist with medical costs. These programs are often offered through the doctor or hospital providing your treatment, and they can help cover remaining costs after insurance or Medicaid payments have been applied. By exploring these various options, you may be able to significantly reduce your financial burden when facing medical expenses.
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How to pay medical bills
Paying medical bills can be a complicated process, and it's important to understand your health insurance plan and its benefits. Both the insured and insurer share financial responsibility, and it is the insured's job to understand the health plan and how it works. Typically, you will pay a medical bill only after the provider has submitted a claim to your insurance company and received payment. You may receive an explanation of benefits (EOB) before you receive the bill, which indicates that your insurance company is processing a claim and requires no action from you.
If you are confused about your bill, you should call both the medical provider and your insurance company to learn more. The number for your health insurance company can usually be found on the back of your insurance card. It is worth noting that you may receive multiple bills after hospital treatment, as certain providers, such as specialists, may bill separately. If you were transported to the hospital by ambulance, you may also receive a separate bill for this.
If you are concerned about your ability to pay, you should be upfront about what you can afford with your provider. You can ask them if they are willing to reduce the charges or set up a payment plan, as medical bills can often be negotiated. Many providers can work out a no- or low-interest payment plan, which is a common way to resolve a large bill. If you do not have insurance, you may be charged more, but this can give you leverage in negotiating the bill.
If the insurance company refuses to pay, you can pursue a lawsuit, although this can be a lengthy process. If a bill is left outstanding, the medical provider may take legal action against you, which could negatively impact your creditworthiness.
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Frequently asked questions
If you cannot afford your medical treatment, you can seek help from a law firm that can help you get reimbursement from the at-fault party's insurance company. They can also help you find highly qualified doctors.
The health plan explains who pays for what. It is the insured's responsibility to understand the benefits of the health plan. If you have questions about why your insurance company did not cover something or about the amount you have to pay, contact your insurance company.
If the insurance company refuses to pay, a law firm can file a lawsuit and take the case to trial to make them take responsibility. This can be a years-long process. Only a jury can force the insurance company to pay your medical bills if they refuse to take responsibility.
There are several ways to get help with medical bills:
- Government programs like Medicare, Medicaid, CHIP, the ACA, and COBRA can help with health expenses.
- Charity care programs may assist with remaining costs after health insurance or Medicaid payments.
- Debt management plans can help with a payment schedule that a credit counsellor develops.
