Haris Ashley
Medical billing can be difficult to understand, and insurance doesn't always cover everything. It's important to know what insurance will and won't pay for, and how much they'll pay, before visiting a healthcare provider. After visiting a healthcare provider, they will typically file a claim on your behalf. If your healthcare provider is in-network with your insurance plan, they will zero out the balance. However, if they are out-of-network, you will be billed for whatever the insurance company does not pay for. It's also possible that a claim will be denied, in which case you will be responsible for the entire bill. To avoid unexpected medical bills, it's crucial to understand health insurance claims and take proactive steps such as obtaining pre-approvals, verifying in-network status, and reviewing itemized bills.
| Characteristics | Values |
|---|---|
| What to do if you get a hospital bill | Step 1: Check if the bill contains the words "insurance pending" or any other indication that the hospital has submitted the bill to the insurance company. If it does not, proceed to Step 2. |
| Step 2: Call the hospital and ask them to bill your insurance company. Provide them with the information on your insurance card/certificate. If the hospital refuses or is unable to do this, proceed to Step 3. | |
| Step 3: Fill out the relevant reimbursement form and submit it as per the provided instructions. Include an itemized statement, which can be either the bill received or the statement provided by the hospital if you paid the bill yourself. | |
| How to avoid unexpected medical bills | Understand your health insurance plan: Know what services and treatments are covered, and how much your insurance company will pay for each service. Ask what insurance will and will not pay for, and how much they will pay, before visiting a healthcare provider. |
| Verify your healthcare provider is in-network: If a provider is out-of-network, they will bill your insurance company for the service and then charge you for the balance that insurance won't cover. This can result in unexpected medical bills. | |
| How to handle a high medical bill | Question the bill: Ask for an itemized bill and review it to ensure all charges are recognized and correct. Check dates, providers, and procedure codes. |
| Identify red flags: Be wary of billing scams, which may include legitimate-looking bills for phony services, unfamiliar billing addresses, or requests for sensitive information. | |
| Confirm insurance billing: If a bill is higher than expected, verify that your insurance company has been billed correctly. Compare your itemized statement to the explanation of benefits provided by your insurer. | |
| Identify surprise billing: Surprise billing occurs when a patient receives care from an in-network provider, but an out-of-network provider also becomes involved without the patient's consent. This can result in unexpected charges. | |
| Negotiate the bill: You may be able to negotiate a discount, interest-free payment plan, or other compromises to reduce the financial burden. | |
| Work with a medical billing advocate: They can help identify abusive, fraudulent, or erroneous billing practices and negotiate with healthcare providers on your behalf. |
What You'll Learn
- Ask the hospital to bill your insurance company
- Compare your itemized statement to the explanation of benefits provided by your insurer
- Confirm the hospital has billed your insurer correctly
- Check if your insurance company requires additional information
- Contact your insurer if you need help disputing a bill
Ask the hospital to bill your insurance company
If you receive a hospital bill in the mail, the first thing to do is to check whether it contains the words "insurance pending" or any other indication that the hospital has already submitted the bill to your insurance company. If it doesn't, call the hospital and ask them to bill your insurance company. Provide them with the information on your insurance card or certificate. If the hospital refuses to send the bill to your insurance company, or if it is not possible for them to do so, you may need to fill out a reimbursement form and submit it to your insurance company.
It is important to know that you can say no to prepaying for medical care. It is usually better to wait for the bill from the hospital and then confirm with your insurance company how much you need to pay. Hospital bills can be complex and confusing, and it is not always clear whether the insurance company has been billed correctly. Before paying any medical bill, ask yourself the following questions:
- Do I need an itemized bill?
- Do I recognize all the charges?
- Are the dates, providers, and procedure codes correct?
- Are there any red flags indicating a potential scam?
- How old is the bill?
- Has my insurance been billed properly?
- Was I billed for an out-of-network provider?
- Can I negotiate the balance?
- Do I need help disputing this bill?
If you are unsure about any aspect of the bill, contact the hospital's billing department and your insurance provider to clarify. It is also worth noting that, in some cases, hospitals may offer discounts for patients who pay their bills in full in advance. If you decide to pay in advance, don't forget to ask for a discount.
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Compare your itemized statement to the explanation of benefits provided by your insurer
Comparing your itemized statement to the explanation of benefits provided by your insurer is a crucial step in ensuring you are not overcharged for medical services and that your insurance is billed correctly. Here are some detailed instructions on how to do this:
Firstly, understand that you should receive an itemized bill or statement from your healthcare provider, which breaks down the charges for the services you received. This statement may be provided to you digitally, through an online account, or you may need to request it by calling your provider. This itemized statement should include dates, providers, procedure codes, and other relevant details for each charge.
Next, you should receive a separate explanation of benefits (EOB) statement from your insurance company for each bill they receive. This EOB will outline what your insurance plan covers and how much they will pay for each service. It will also indicate your financial responsibility, including any deductibles, copays, or coinsurance amounts.
Now, you can compare your itemized statement from the healthcare provider with the EOB from your insurer. Ensure that the services listed on both documents match. Check that the dates, providers, and procedure codes align. If there are any discrepancies, contact your healthcare provider and ask them to bill your insurance company for any missing services.
Additionally, confirm that the charges on your itemized statement are correct and align with your understanding of your insurance coverage. For example, if you were treated at an in-network facility, verify that you are only being billed for your in-network cost-sharing, such as copays, coinsurance, or deductibles. If you identify any errors or discrepancies, don't hesitate to contact your insurance company and your healthcare provider to resolve the issues.
By carefully comparing these documents, you can ensure that your insurance is billed correctly and that you are not overcharged for medical services. It is important to stay engaged and ask questions to confirm that you are being billed correctly and to avoid unexpected costs.
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Confirm the hospital has billed your insurer correctly
Confirming that the hospital has billed your insurer correctly is a crucial step in ensuring your insurance covers your hospital bill. Here are some detailed steps to help you through this process:
Firstly, carefully review the hospital bill. Ask the hospital for an itemized bill if you don't already have one. This will break down the charges for each service provided during your stay. Check that you recognise all the charges, and confirm that the dates, providers, and procedure codes listed are correct. It is essential to verify that the hospital has not made any errors or included any fraudulent charges.
Next, compare the hospital's itemized bill with the explanation of benefits (EOB) provided by your insurer. The EOB outlines the services your insurer has been billed for and the amount they will pay. Ensure that the hospital has billed your insurer for the same services listed on your itemized statement. If there are any discrepancies, contact your provider and ask them to bill your insurer for any missing services.
Additionally, double-check that the hospital has billed your insurer correctly regarding your specific insurance plan. Confirm that the hospital has billed your insurer as an in-network or out-of-network provider, depending on your plan's details. Mistakes in this area can result in unexpected out-of-network charges. Also, verify that your insurer has applied any discounts or negotiated rates that are part of your plan.
If you identify any issues with the hospital's billing, don't hesitate to contact them and your insurer to resolve the discrepancies. It is important to be persistent and polite when dealing with billing issues. Remember that you have the right to dispute any incorrect charges and request that they be corrected.
Finally, keep detailed records of all your communications with the hospital and your insurer. Note the dates and content of phone calls, emails, or letters, and keep copies of any relevant documents. This documentation will be valuable if you need to escalate the issue or provide evidence to support your case.
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Check if your insurance company requires additional information
It is important to check if your insurance company requires additional information to process your claim. This could include referrals or pre-approvals for certain procedures or treatments. For example, some plans require referrals or pre-approvals to see a specialist, and if you get medical care without this pre-approval, your insurer may deny your claim. In this case, be sure to get a referral as soon as possible so that your future visits are covered, and see if your past claims can be reimbursed now that you have a referral.
Additionally, lack of pre-approvals or referrals can result in denied claims. Most plans will only cover medically necessary care, and your insurer may deny your claim if they feel the service was not medically necessary. If this is the case, you can ask your doctor to submit a "Medical Necessity" form on your behalf or any other information requested by your insurance company.
It is also important to verify that your healthcare provider is in your insurance plan's network. If a provider accepts your insurance but is not in-network for your plan, they will bill your insurance company for the service and then charge you directly for any amount that insurance won't pay. If you have a PPO plan, this typically means paying higher, out-of-network costs. But if you have an HMO plan, you may be responsible for the entire cost of the visit.
It is also worth noting that insurance companies can have several plans with different provider networks. Therefore, it is crucial to get confirmation directly from your insurance company, not via your healthcare provider, as the insurance company has the final word on what is covered.
Contact your insurer if you need help disputing a bill
If you need help disputing a bill, contact your insurer. They may have staff who can assist in resolving billing issues. For example, if you have received a surprise bill for medical services after July 1, 2017, and have already paid more than your in-network cost share, file a complaint with your health insurer with a copy of the bill. Your health insurer will review your complaint and should tell the provider to stop billing you.
If you are disputing a charge, ask the medical provider to hold off on sending the bill to collections while you seek a resolution. You can do this with a phone call, but if your issue is complicated and will likely take a while to settle, it’s a good idea to get the hold agreement in writing.
If your health plan isn’t covering something you thought would be covered, call the customer service line and ask directly, “What needs to happen for this to be covered?” The insurer may be missing a key medical record indicating a service was necessary, or the service may have been provided by an out-of-network doctor. Ask your insurer for help in setting the record straight.
If you aren't getting anywhere with the person you're speaking to, ask to speak to a supervisor. If you hit another brick wall, ask for that person's supervisor. It might take several conversations with your insurance company and the doctor's billing office to resolve the issue. For each one, get the information and documents you need to make the case that you were billed in error. For example, search online for the five-digit codes that correspond to each charge on your bill and make sure they reflect the services provided or procedures performed.
If your health plan ultimately denies a claim for treatment, you have the right to appeal. Enlist your doctor’s help: they can write a letter supporting your case and provide documentation, such as journal articles, to support why a certain procedure or treatment was medically necessary. You can file an appeal up to 180 days after you are notified of a denial. The explanation of benefits (EOB) you get from your insurance company will have information about how to file. If you do, your insurer must do what the U.S. Department of Health and Human Services calls a "full and fair review" of its initial rejection. If you lose here, you can request an "external review" by an independent organization accredited to review health care decisions.
Frequently asked questions
First, check if the bill contains the words "insurance pending" or any other indication that the hospital has submitted the bill to your insurance company. If it does, call the hospital and ask them to bill your insurance company. If the hospital refuses or it's not possible for them to do so, fill out a reimbursement form and send it to your insurance company.
Surprise billing occurs when a patient receives care from an out-of-network provider at an in-network facility. Since July 1, 2017, California law has protected consumers from surprise medical bills when they receive non-emergency services at an in-network facility. If you receive a surprise bill, file a complaint with your health insurer and ask them to review it.
Your insurance company must notify you in writing about why your claim is being denied and provide information about the appeals process. Common reasons for denied claims include errors in processing your claim, out-of-network providers, missing information, lack of pre-approvals/referrals, and services not covered by your insurance. Contact your insurance company and healthcare provider to rectify any errors and go through the appeals process if necessary.
Always ask about what your insurance will and will not cover, and how much they will pay for, before visiting a healthcare provider. Verify that the provider is in your insurance plan's network, as simply accepting your insurance is not the same as being in-network. Understand your insurance plan's coverage, including any deductibles, copays, and coinsurance, to avoid unexpected costs.
You can try to negotiate with the hospital or healthcare provider to set up an interest-free payment plan or request a discount for immediate payment. Many hospitals also have financial assistance programs. Alternatively, you can work with a medical billing advocate to reduce your costs by identifying erroneous or fraudulent billing practices. Be persistent but polite, and keep good documentation of your efforts.
