Navigating The Insurance Billing Maze: Unraveling The 'Which Insurance To Bill' Conundrum

Medical billing can be a confusing process, with 72% of American consumers reporting confusion over their medical bills. If you have insurance, you may be wondering which insurance company to bill for your care. This will depend on the type of care you require and the insurance plan you have. Generally, insurance companies cover the costs for preventive care, such as check-ups and vaccinations. For other services, insurance companies may require you to cover all costs until you reach a specified amount, known as a deductible. Once you've reached this amount, the insurance company will start paying for covered services. It's important to understand your insurance coverage and what you are expected to pay for healthcare services.

Understanding medical bills

Medical billing in the United States can be a confusing process, with many consumers finding their medical bills too expensive and difficult to understand. However, understanding your medical bills is important to know what to expect financially when you need to go to the doctor. Here is a guide to help you navigate the medical billing process and understand your medical bills.

How the Billing Cycle Works

After visiting a healthcare provider, your doctor's office will submit a bill, also called a claim, to your insurance company. This claim lists the services your doctor provided to you, and the insurance company uses this information to pay your doctor for those services.

Explanation of Benefits (EOB)

When the insurance company pays your doctor, they might send you an Explanation of Benefits (EOB). This document is not a bill but shows what the insurance company did when they received your doctor's bill. It explains what medical treatments and services the insurance company agreed to pay for, and what you are responsible for paying. It is important to read and understand the EOB to know what your insurance company is paying for, what it's not paying for, and why.

Statement from Doctor's Office

You might also receive a statement from your doctor's office, which shows how much they billed your insurance company for the services you received. If you receive this statement before your insurance company pays your doctor, you do not need to pay the amounts listed. After your insurance company pays your doctor, you may need to pay your doctor any remaining balance.

Understanding Your Bill

When you receive a medical bill, it will consist of multiple components that might not be clear to you. Here are some key terms to help you understand your bill:

• Statement Date: The date your healthcare provider printed the bill.
• Account Number: Your unique account number, which you need to provide when contacting your healthcare provider's billing office.
• Service Date: The dates you received each medical service.
• Description: A short phrase explaining the service or supplies you received.
• Charges: The full price of the services or supplies before insurance has been factored in.
• Billed Charges: The total amount charged directly to you or your insurance provider.
• Adjustment: The amount the healthcare provider has agreed not to charge.
• Insurance Payments: The amount your health insurance provider has already paid.
• Patient Payments: The amount you are responsible for paying.
• Balance/Amount Due: The amount currently owed to the healthcare provider.
• Payable to: The organization you should address cheque payments to.

Dealing with Billing Errors

Medical billing errors can occur due to mistakes in coding, data entry, or claims adjustments. Here are some steps you can take to identify and dispute erroneous charges:

• Compare estimates to your final bill: Contact the healthcare provider before your appointment to get the billing code and cost, and then contact your insurance provider to confirm coverage and obtain an estimate.
• Create a list of charges: Keep a record of all the medical services and supplies you received, along with their corresponding charges.
• Duplicate charges: Look out for the same charge listed twice, as this could be a data entry error.
• Beware of upcoding: Upcoding is the criminal act of fraudulently reporting an incorrect diagnosis to profit from higher payments.
• Check identifying information: Ensure your name and identification numbers are correct to avoid insurance coverage discrepancies.
• Contact your healthcare provider and insurer: Speak to your healthcare provider about any bill inaccuracies and, if needed, contact your insurer to dispute the charge and file a formal appeal.
• Contact a credit-reporting agency: Ensure that any disputed bills do not negatively impact your credit score.

Insurance coverage and patient payment

Understanding Insurance Coverage

Insurance coverage can be confusing, and it's important to know what to expect financially when you need to go to the doctor. The first step is to understand what your insurance covers and what you need to pay for yourself. This can vary depending on your insurance plan and the specific medical services you receive.

Understanding Your Medical Bills

After you visit your doctor, their office will typically submit a bill (also called a claim) to your insurance company. This claim lists the services provided to you, and the insurance company uses this information to determine how much they will pay for these services.

The insurance company will then send you a report called an Explanation of Benefits (EOB), which details what they did when they received the bill from your doctor. It shows what they paid for, what they didn't, and why. It's important to understand your EOB to know what you're responsible for paying.

Your doctor's office might also send you a statement, which shows how much they billed your insurance company for the services you received. If you receive this before your insurance company pays your doctor, you don't need to pay anything at that time. After your insurance company pays their portion, you may need to pay any remaining balance.

Understanding Your Responsibilities as a Patient

As a patient, you are generally responsible for paying a portion of your medical bills, known as "patient responsibility". This typically includes:

• Co-payment: A fixed, flat fee that you pay towards your medical care at the time of service.
• Deductible: The total amount you must pay towards your medical care each year before your insurance company contributes.
• Coinsurance: Your share of the remaining medical costs after paying your deductible.
• Out-of-pocket maximum: Some health plans set an annual limit to how much you need to pay, including co-payments, deductibles, and coinsurance. Once you reach this limit, your insurance company will cover all eligible expenses for the rest of the period.

It's important to understand your insurance coverage and patient responsibilities to avoid unexpected costs and ensure you can plan for any necessary medical care.

Insurance jargon and procedural codes

Navigating the world of insurance can be challenging, with its complex procedures and jargon. However, understanding procedural codes and insurance terminology is essential for both healthcare providers and patients to ensure accurate billing and reimbursement.

Procedural Codes

Procedural codes, also known as Current Procedural Terminology (CPT) codes, are standardised alphanumeric codes assigned to specific medical services or procedures. These codes serve as a universal language, enabling effective communication between healthcare providers, insurance companies, and other stakeholders. CPT codes consist of five characters, mostly numeric, but some may include a fifth alpha character such as F, T, or U.

Each CPT code corresponds to a specific service and has a description outlining the procedure performed. For example, CPT code 99213 represents an Evaluation and Management (E&M) service provided by a physician for a patient with a moderate severity problem. CPT codes cover a range of services, including diagnostic tests, surgical interventions, medical treatments, and other healthcare services.

International Classification of Diseases (ICD) Codes

While CPT codes describe the services or procedures rendered, International Classification of Diseases (ICD) codes serve a different purpose. ICD codes are used to record a patient's diagnosis, symptoms, or medical condition. They provide a standardised system for classifying diseases and health conditions, enabling consistent data collection for statistical and epidemiological purposes. By combining CPT and ICD codes, healthcare providers can communicate the "what" and "why" of a patient's visit and treatments.

Understanding Your Medical Bills

Reading and understanding your medical bills is crucial. Your medical bill will typically include the statement date, your unique account number, service dates, descriptions of services, charges, adjustments, insurance payments, patient payments, and the amount currently owed.

In addition to your medical bill, you may also receive an Explanation of Benefits (EOB) from your insurance company. The EOB details how your insurance company handled the claim submitted by your healthcare provider. It outlines the total charges, allowed amounts, non-covered charges, insurance payments, and any patient responsibility amounts, such as co-pays, co-insurance, and deductibles. It's important to note that an EOB is not a bill, and you should refer to your actual medical bill for the amount owed.

Common Insurance Terms

• Copay or Copayment: A fixed dollar amount that you pay each time you receive medical care. For example, you may have a $20 copay for a doctor's appointment.
• Deductible: A specified amount you must pay within a defined period before your insurance company starts covering a portion of the costs.
• Coinsurance: Instead of a fixed copay, you may be required to pay a percentage of the total costs as coinsurance. For example, your insurance may cover 80% of the cost, and you pay the remaining 20%.
• Maximum Out-of-Pocket (MOOP) Expense: The maximum amount you'll have to pay for your medical costs within a given time period, usually a year. Once you reach this limit, your insurance will cover 100% of the costs.

Insurance claim submission

The process of submitting an insurance claim can be complicated and confusing, but it is important to know how to do it correctly to avoid unnecessary costs and delays. Here is a detailed guide on insurance claim submission:

Step 1: Understand Your Insurance Coverage

Before seeking treatment, it is crucial to understand what your insurance plan covers. Different plans have varying levels of coverage, and some procedures may not be included. Knowing what is covered will help you avoid unexpected costs. Contact your insurance company to clarify any doubts about your coverage.

Step 2: Visit Your Doctor or Healthcare Provider

When you need medical care, visit your doctor or healthcare provider. They will provide the necessary treatment and services. Make sure to ask about the costs involved and what your insurance might cover. After your visit, your doctor's office will typically submit a bill, also known as a claim, to your insurance company.

Step 3: Receive an Itemized Bill

Obtain an itemized bill from your doctor or healthcare provider. This bill should list all the services provided, along with the associated costs and special codes. These codes are important for insurance reimbursement.

Step 4: Fill Out a Claim Form

Obtain a claim form from your insurance company, usually available on their website. This form will require detailed information about the accident, illness, or treatment. Provide personal information, insurance policy details, background information about your condition, and any out-of-pocket expenses you have incurred. You may need to attach additional pages if more space is needed. Make sure to follow the instructions on the form and include all relevant documentation.

Step 5: Make Copies of Your Documents

Before submitting your claim, it is essential to make copies of all your documents, including the completed claim form and itemized receipts. Keep these copies in a safe place in case of future disputes or complications.

Step 6: Submit Your Claim

Contact your insurance company to inform them that you will be sending in a claim form. Review the paperwork with them to ensure you have included all the necessary information and documents. Submit your claim form and accompanying paperwork by mail, email, or fax, depending on the options provided by your insurance company. Keep a record of the submission date and any reference numbers provided.

Step 7: Follow Up on Your Claim

After submitting your claim, stay in touch with your insurance company to ensure they have received all the necessary documents and that they are filled out correctly. If there are any issues or delays, address them promptly. Keep a record of all communications and correspondence related to your claim.

Step 8: Receive an Explanation of Benefits (EOB)

Once your insurance company processes your claim, they will send you an Explanation of Benefits (EOB). This document explains what treatments and services your insurance company agreed to pay for and what portion you are responsible for paying. It is important to carefully review the EOB to understand your financial responsibilities.

Step 9: Pay Any Remaining Balance

If there is a remaining balance after insurance reimbursement, you will need to pay the doctor or healthcare provider directly. This balance may include deductibles, co-payments, or services not covered by your insurance.

Remember that the specific steps and requirements may vary depending on your insurance provider and your location. Always review your insurance policy and stay in close communication with your insurance company and healthcare providers to ensure a smooth claim submission process.

Dealing with billing errors

Know Your Health Plan

Many billing problems occur because people don't understand the basics of their insurance, including deductibles, coverage limits, and the network of providers. Make sure your provider has the correct insurance information on file. Read your health plan document, which should be available on your insurer's or employer's website. This will tell you what your plan does and doesn't cover, as well as any limits for treatments.

Compare Costs

If you can, try to determine your charges in advance. Ask your doctor what they are ordering and talk to the billing office to get the billing codes. Once you have these, ask your insurer what and how much they will cover. You can also use online tools like FAIR Health, Clear Health Costs, or Healthcare Bluebook to check prices in your area.

Check Paperwork

After receiving care, you will get paperwork from both your care provider and your insurer. Your provider will send you a bill, and you will also get an Explanation of Benefits (EOB) from your insurer. The EOB explains the services you received, what your insurer covered, what they paid, and what you owe to the care provider. File the EOB with your other bills and keep them for your records. If any information on the EOB doesn't match the bill from your provider, call your care provider or insurer to clarify.

Act Quickly

If you receive a bill that seems incorrect, address the problem as soon as possible. Call your provider and your insurer and explain why the bill seems wrong. If your provider made a mistake, they may need to resubmit the claim with corrections. If this doesn't work, try to diagnose the problem and find out who can solve it. Be aware that providers often set a time limit on bill payment, so if there is a dispute, notify the billing office in writing to freeze the account.

Get Help

If you aren't having any luck with your insurer or care provider, there are other support options. You can submit a complaint to the Centers for Medicare and Medicaid Services or call the No Surprises Help Desk. You can also seek help from your employer's benefits department or a medical billing advocate, who can help negotiate with your provider or insurer.

Try Negotiating

If you can't dispute a charge, you may be able to negotiate. Check online resources to figure out fair prices in your area, and ask your provider if they can lower their fee if you were overcharged. You can also ask for a payment plan to pay off your bill in instalments, or inquire about financial assistance programs. Nonprofit hospitals are required to offer "charity care," and many for-profit and private hospitals also offer discounted care for those in financial need.

Frequently asked questions