Navigating Insurance Billing Errors: A Step-By-Step Guide To Taking Action

Dealing with insurance can be a complicated and frustrating process. If you believe your insurance has been billed incorrectly, there are several steps you can take to resolve the issue. First, contact your medical provider and ask for an itemized bill. This will allow you to review each charge and identify any errors or discrepancies. Compare these charges with your insurance plan to determine what is covered by your provider and what is your responsibility. You should also request an Explanation of Benefits (EOB) report from your insurance company, which outlines what they have covered for a specific date and healthcare visit. If you identify any issues, contact both your medical provider and insurance company to discuss the discrepancies and request corrections if necessary. It is important to act quickly, as most providers have a time limit on bill payment. If issues persist, consider seeking help from a medical advocacy agency or a patient advocate, who can work on your behalf to find a solution.

Check for double billing

Double billing is a common issue in the medical billing industry and it can have serious consequences for patients, insurance companies, and healthcare providers. It occurs when a healthcare provider attempts to bill for the same service more than once, or when two providers attempt to bill for services provided to the same patient for the same procedure on the same date. This can happen due to clerical or system errors, or in some cases, intentional fraud.

To check for double billing, you can take the following steps:

• Request an itemized bill from your healthcare provider and review it carefully. Look for any duplicate charges or coding mistakes.
• Compare the itemized bill against your insurance plan to determine which charges are your responsibility and which are covered by your insurance company.
• Contact your insurance company and request an Explanation of Benefits report, which outlines what they have covered for a specific date and healthcare visit. Ensure that this matches the bill from your healthcare provider.
• Ask your healthcare provider for a copy of your medical records and compare them to your bill. You should not be billed for anything that is not documented in your records.
• If you received care from multiple providers, pay close attention to the billing from each provider to ensure you are not being double-billed for the same service.
• Look up the medical billing codes for each item on your bill and compare them to the descriptions online. Ensure that the billing codes match the care you received.
• Reach out to a patient advocate for assistance if needed. They can help you navigate the complex world of medical billing and protect your rights.

By following these steps, you can help identify and resolve instances of double billing, reducing financial losses and preserving trust between patients, insurance companies, and healthcare providers.

Contact your insurance company

If you believe your insurance wasn't billed correctly, it's important to contact your insurance company to resolve the issue. Here are some steps you can take:

• Review your insurance plan: Familiarize yourself with the details of your insurance coverage, including deductibles, coverage limits, and in-network providers. Understanding your plan will help you identify any discrepancies or errors in billing.
• Gather relevant information: Collect all the necessary documents, such as your insurance policy, medical bills, itemized billing statements, and explanation of benefits (EOB) from your insurance company. Having this information readily available will be helpful when discussing the issue with your insurance company.
• Identify potential errors: Carefully review your medical bills and compare them with your insurance coverage. Look for double charges, coding mistakes, incorrect calculations, or services that should be covered by your insurance plan.
• Contact your insurance company: Get in touch with your insurance provider by calling their customer service line or using their online support system. Explain the issue you have identified and provide them with the relevant documentation. Ask them to review the charges and correct any mistakes. It is important to act quickly, as there may be time limits for filing appeals or disputes.
• Provide supporting documentation: If needed, provide letters or records from your medical provider that support your claim. For example, if your doctor disagrees with your insurer's denial of coverage, ask them to provide a letter explaining their position. This can strengthen your case when dealing with the insurance company.
• Keep detailed records: Throughout the process, maintain a record of your communications with the insurance company. Note the dates and summaries of conversations, as well as the names of the representatives you speak with. This information may be important if you need to file complaints or escalate the issue further.
• Follow up: Stay in regular contact with your insurance company to check on the status of your case. Billing errors can sometimes take time to resolve, so it's important to be persistent and follow up at appropriate intervals.
• Seek additional support: If you are having difficulty resolving the issue on your own, consider seeking assistance from a medical advocate or a patient advocacy group. They can help you navigate the process and work with your insurance company to find a solution.

Remember, it is important to act promptly when dealing with insurance billing issues. There are often time limits for filing appeals or disputes, and delaying the process may result in your bill being sent to a collections agency, which can negatively impact your credit score.

File an appeal

If your insurance company refuses to pay a claim or ends your coverage, you have the right to appeal the company's decision and have it reviewed by a third party. The law allows you to have an appeal with your insurer as well as an external review from an independent third party.

The first step in challenging your bill is to ask for an itemized copy. When your bill is itemized, every charge is clearly listed so that you can see what you’re paying for. Go through this bill line by line and look for double charges, coding mistakes, and incorrect calculations. Compare the items against your health insurance plan for charges you’re responsible for versus what your insurance company is responsible for. Then check your bill for any charges listed that should be covered by your provider.

If you think there’s been a mistake, call your insurance company and ask them to explain why the claim was denied. Be sure to ask if the claim was denied because of a billing error or missing information. If you think a mistake has been made, ask the representative to go over the process with you or to send you a description of how to appeal. Keep records. Write down the name of the person you spoke to, the date, and what was decided.

If your insurance company refuses to pay the claim, you have a right to file an appeal. You must follow your plan's appeal process. Check your plan's website or call customer service. You'll need detailed instructions on how to file an appeal and how to complete specific forms. Be sure to ask if there is a deadline for filing an appeal.

If you're filing an appeal, let your doctor or the hospital know. Ask that they hold off on sending you bills until you hear back from your insurance company. Also, make sure that they won't turn your account over to a collections agency.

The first step in an appeal is called an internal review. It begins when you file an appeal of a denied claim. Your claim will get a second look by insurance company employees who weren't involved in the original decision. If you are in an urgent medical situation, you can request an expedited appeal that requires the insurance company to make a decision within 72 hours. After the internal review, your insurance company will call or send you a letter about its decision. If the insurance company overturns the initial decision, your care will be covered. If it upholds the decision, you still have other options.

If you're not happy with the outcome, you can take it to the next level. Ask for an external appeal. People who don't work for your insurance company—called an independent third party—will do their own review.

You can get help filing an appeal. Your state may have a Consumer Assistance Program that can answer questions and guide you through the process.

Contact a medical billing advocate

If you're feeling overwhelmed by medical bills, a medical billing advocate might be the solution you need. They can help you understand, negotiate, and reduce your medical bills.

When to Contact a Medical Billing Advocate

• If you don't understand your medical bills or the codes that have been used by your medical providers, and the explanations given by your providers don't make sense.
• If you have a significant number of bills (which can happen even from a single complex medical incident), some of which might need to be questioned, and you don't have time to wait on hold with your insurance company or the medical providers' offices.
• If you're dealing with a chronic medical condition that involves a steady stream of medical bills, and you don't want to fall behind on managing them.
• If your health insurance is refusing to pay part or all of your medical bills and the reason doesn’t make sense or seems wrong.
• If your health insurance company and your hospital or doctor's office are blaming each other, and you’re stuck in the middle, holding the bill.
• If you’re overwhelmed with medical bills that you can’t possibly pay and you’re considering bankruptcy because of them.
• If you have no insurance and you’re not good at negotiating. A medical billing advocate can negotiate lower bills in advance or after the fact.
• If you’re so sick that you no longer have the energy to deal with the volume of paperwork required to manage your medical bills and health insurance coverage, but you don't want family or friends to have to do it for you.
• If you’re responsible for managing the medical bills of someone else (perhaps an elderly parent) and either can’t make sense of them or are overwhelmed by what’s involved with keeping track of them.

What the Advocate Will Need

• Your health insurance information, as well as details about any secondary or supplemental insurance coverage that you may have.
• Your explanation of benefits (EOB) forms.
• Your permission to speak with your healthcare providers and your health insurance company.
• Access to your medical records.
• Information about what you’ve paid already.
• Information about what steps you’ve taken to resolve the issue prior to getting the medical billing advocate involved.

How to Find a Medical Billing Advocate

You can find medical billing advocates using the AdvoConnection directory. Check with your employer's human resources department; some employers provide medical billing advocacy services as part of their benefits package, either for free or at a reduced rate. You can also find a medical billing advocate in your area by contacting the not-for-profit Alliance of Claims Assistance Professionals (ACAP), which covers 18 states, or the Medical Billing Advocates of America.

Compare billing codes to your bill

Comparing billing codes to your bill is an important step in checking for errors and making sure you're not being overcharged. Here's how to do it:

Firstly, you'll need to get an itemized bill from your medical provider. This will list each service and medical supply you received, along with the dollar amount for each one. You are entitled to an itemized bill, but you usually have to request it.

Your bill will include a range of codes, which can be confusing. There are a few types of codes:

• HCPCS Level I codes, or CPT codes, are used by all U.S. providers and consist of five digits that correspond to different procedures or tests.
• HCPCS Level II codes correspond to supplies or products used during your visit and often start with a letter.
• ICD-10 codes identify diagnoses. In the U.S., every billed service with a CPT code must link to an ICD code to ensure the treatment matches the diagnosis.
• Revenue codes are specific to a facility and identify the dollar amount linked to a procedure.

You can look up these codes online to make sure they match the care you received. Use a search engine to look up the medical billing code for each item on your bill. Type the code number along with the term "medical billing code" and read the descriptions. Check that the billing codes match the care you got and contact your provider's billing department if they don't.

It's worth noting that medical billing can be complicated, and you may want to reach out to a patient advocate for assistance.

Frequently asked questions