Understanding Insurance Billing: Timing And Procedures

The billing and payment process can be complex and confusing. Generally, insurance companies cover the costs for preventive care throughout the year, such as check-ups and vaccinations. For other services, insurance companies require you to cover all costs until you reach a specified amount, known as a deductible. Once you reach this amount, the insurance company starts paying for covered services. After receiving care, the hospital or healthcare provider will send a bill to your insurance company. They will then determine how much they will pay for a service or visit, and how much you are responsible for. The insurance company must then pay the bill within 60 days.

Insurance billed after receiving care

The billing process for insurance can be complex and confusing. Typically, after receiving care, the healthcare provider will send a bill to your insurance company. The insurance company will then determine how much they will pay for the service or visit, and how much you are responsible for. This breakdown is shown on the Explanation of Benefits (EOB) provided by the insurance company. The healthcare provider will then send you a bill for the amount you owe.

The timing of billing can vary depending on the healthcare provider and insurance company. In some cases, the healthcare provider may collect all known fees upfront, including deductibles, co-payments, and co-insurance. These fees are usually based on estimated charges for the service and may be adjusted after confirming the actual services provided during your visit. If the final bill is higher than the estimate, you may be asked to pay the difference upon discharge. If it is lower, you should receive a refund for the difference.

It's important to understand the terms of your insurance plan, as many plans have different coverage levels and out-of-pocket costs. Generally, insurance companies cover the costs for preventive care, such as check-ups and vaccinations. For other services, you may be required to cover all costs until you reach a specified amount, known as a deductible. Once you reach this deductible amount, the insurance company will start paying for covered services.

Additionally, there are other key insurance terms to be aware of:

• Copay (copayment): a fixed dollar amount that you pay each time you receive medical care.
• Coinsurance: instead of a fixed amount, you may be required to pay a percentage of the total costs.
• Maximum out-of-pocket (MOOP) expense: the maximum amount you'll have to pay for medical costs in a given time period, usually a year.

Understanding these terms can help you navigate the billing process and know what to expect in terms of costs and coverage.

Insurance billed for preventive care

Preventive care is a way to detect or prevent serious diseases and other medical issues from worsening. It involves regular check-ups, tests, and screenings to identify health issues early on. Since the passing of the Affordable Care Act (ACA), health insurance plans must cover 100% of preventive care. This means that annual physicals, tests, and screenings are fully covered, with no out-of-pocket costs for the patient. This includes plans available through the Health Insurance Marketplace.

Prior to the ACA, policyholders often had to pay for all or some of their preventive care. Now, insurance plans must cover preventive care services with no cost-sharing, such as copays, coinsurance, or deductibles. This is true for all non-grandfathered major medical plans in both the individual/family and employer-sponsored markets. However, it's important to note that preventive care is only covered if it is delivered by a doctor or provider in the patient's plan network.

Some common examples of preventive care include:

• Yearly physicals or check-ups
• Flu shots
• Mammograms
• Colonoscopies
• Vaccinations
• Well-woman visits

Despite the ACA's improvements, some patients still receive unexpected bills for preventive services that should be free. A study found that total out-of-pocket costs billed for preventive services to Americans with employer-sponsored insurance in 2018 ranged from $75.6 million to $219 million, with 1 in 4 patients who used preventive care incurring these charges. These unexpected costs may discourage people from seeking recommended preventive care.

To avoid unexpected charges, it's important to use an in-network medical provider and understand exactly what tests or services will be provided during the visit.

Insurance billed for non-preventive care

Preventive care is distinct from diagnostic care, which involves a doctor diagnosing an illness or condition based on symptoms. It is also different from non-preventive care, which includes additional primary care visits, specialist visits, and alternative therapies. These types of care are typically not covered by insurance as preventive care and may result in out-of-pocket expenses for patients.

Additional Primary Care Visits

Most health insurance plans cover one annual check-up with a primary care physician. Any additional visits during the same calendar year are generally not considered preventive care and may not be covered by insurance. For example, if an individual experiences flu symptoms and needs to see their doctor, this would not be covered as preventive care.

Diagnostic Tests and Screenings

Diagnostic tests and screenings that are not routine fall under non-preventive care. For instance, if a radiologist detects something on a mammogram and requests further imaging, this would be considered a diagnostic mammogram, which is typically not covered as preventive care.

Specialist Visits

Visits to specialists such as gastroenterologists, orthopaedists, neurologists, or podiatrists for specific problems are not covered as preventive care. These visits are often necessary for diagnosing and treating specific conditions but are separate from preventive care services.

Alternative Therapies

Alternative health services, including chiropractic, massage, and acupuncture, are not considered preventive care. These therapies are typically sought for pain management, stress relief, or complementary treatment but are not covered by insurance as preventive care services.

It is important to understand the distinction between preventive care and non-preventive care when anticipating insurance coverage. While preventive care services are typically covered at no cost to the patient, non-preventive care may result in out-of-pocket expenses, depending on the individual's insurance plan and specific circumstances.

Insurance billed for hospital services

The billing process for hospital services can be complex and often involves multiple parties, including the patient, the insurer, and the healthcare provider. Here is a detailed guide on insurance billing for hospital services, outlining the steps, key considerations, and protections for patients.

Understanding the Billing Process

The billing cycle for hospital services typically begins when a patient contacts a healthcare provider and schedules an appointment. During this pre-registration process, the patient provides basic information, such as identification and insurance details. It is important for patients to inquire about the services and supplies they will receive and their associated costs. Healthcare providers should be able to provide procedure codes that patients can use to understand their charges.

Verifying Insurance Coverage

Before the appointment, patients should contact their insurance company to verify if the scheduled services are covered by their plan. The insurance company will also determine the patient's out-of-pocket expenses, including co-pays and deductibles. This step is crucial for patients to understand their financial responsibilities.

Insurance Claim Submission

After the patient receives the medical services, the healthcare provider creates an insurance claim using standardized codes for the services, prescriptions, and supplies provided. This claim, along with the patient's insurance information, is then submitted to the insurance company for reimbursement. The insurance company reviews the claim and verifies that the treatments received are covered under the patient's plan.

Insurance Reimbursement and Patient Billing

If the insurance claim is valid, the insurance company reimburses the healthcare provider directly for some or all of the services rendered. If the claim is rejected, the insurance company provides a detailed explanation for the denial of coverage. The healthcare provider then bills the patient for any remaining balance not covered by insurance.

Understanding Your Bill

Medical bills can be confusing, with various components such as service dates, descriptions, charges, adjustments, insurance payments, and patient payments. It is important for patients to carefully review their bills and understand each itemized charge. Patients should also be aware of potential billing errors and discrepancies and contact their healthcare provider or insurer if they identify any issues.

Protections Against Surprise Billing

Surprise medical billing occurs when patients receive unexpected bills from out-of-network providers or facilities. To protect patients from these unexpected charges, the No Surprises Act (NSA) was implemented, effective January 1, 2022. The NSA limits out-of-pocket expenses for emergency services, out-of-network cost-sharing, and balance billing for supplemental care provided by out-of-network providers at in-network facilities. Patients have the right to dispute surprise medical bills and can utilize the NSA's independent dispute resolution process to resolve billing disagreements.

Insurance billed for professional services

Professional billing is a necessary procedure that covers many administrative duties related to medical practices, such as scheduling appointments, greeting patients, verification and registration, and payment processing. It is important to note that specific inpatient and outpatient treatments will be invoiced under the patient's insurance plan.

The billing process for professional services typically involves the following steps:

• The medical provider submits a bill to the patient's insurance carrier.
• The insurance company determines how much they will pay for the service or visit.
• The insurance company sends an Explanation of Benefits (EOB) to the patient and the provider, outlining the breakdown of costs.
• The provider sends a bill to the patient for the remaining amount owed, known as the patient responsibility.

It is important to understand that insurance plans are typically cost-sharing agreements between the insured and the insurance company. While insurance companies may cover preventive care, they often require the insured to cover all costs up to a specified amount, known as a deductible, before they start paying for covered services.

Additionally, different types of billing forms are used for professional billing, such as the CMS-1500 form or its electronic counterpart, the 837-P. Understanding the distinction between professional and institutional billing is crucial in the healthcare industry, as they differ in the scope of services and billing processes involved.

Frequently asked questions