Navigating your medical bills is not a fun topic, but unfortunately, it’s something most of us encounter in our lives. Medical billing is like a foreign language to anyone who isn’t in that industry and comes with a lot of questions and confusion. How do I know? Well for the last 11 years, I’ve been the practice administrator for a small medical office. Health insurance from the provider side is what I do. In the last few years, major changes have happened in healthcare and the confusion over medical billing has grown. So, just in case you’ve been hit with a medical bill you can’t decipher, I figured I would share with you what I know!
1. Double Check Your Bills: When a bill is submitted to your insurance they will adjust that claim to the contracted allowable amount and then they will pay it, apply it to your deductible or deny it all together.
That means, your doctor can only collect what the insurance company allows. So, we may submit a bill for $125.00 for a routine office visit, but our agreement with your insurance company allows $85.00 for that visit. So, we adjust our bill down the amount. Why do we bill more? We bill more because every insurance company allows a different amount so we bill a higher amount to catch every variable.
When you receive a bill, log on to your online account with your insurance company and take a look at your explanation of benefits. Does the amount on your bill match the amount that the insurance company says you owe? If so, go ahead and pay the bill. If not, call the office and notify them that there is an error with your bill. If they do not correct it, call your insurance company and notify them that you received a bill that did not match the statement. They will then contact your provider and request that it is corrected. It is written in your physician’s contract with your insurance company that they cannot bill a patient for an amount above the allowable amount. It is unlawful, so if they fight you on it, don’t give in. Keep in mind that with the volume that many practices have, mistakes can and will happen, so often this scenario is just a mistake.
2. Know Your Benefits: Most of the bills you receive will be due to a co-pay, deductible or co-insurance. Every plan has its own limits and benefits so check what the benefits are on your personal plan before having services done. Because every plan is so different, your doctor’s office will not know the ins-and-outs of your benefits off hand. They can definitely look them up for you and some offices will, I would, but, you will be better prepared if you know your benefits well.
The best way to navigate your personal costs is to speak with your insurance company, prior to having a particular procedure done. You can ask your doctor what CPT codes they will be billing, then provide those codes to your insurance company and ask them what your benefits are. Some offices and facilities will pre-check this for you and will ask for payment up front, if you pay up front, keep record of any payments made to ensure that proper credit is given to your account!
Keep in mind, you are not always responsible for paying for an uncovered service.Double check the explanation of benefits in your online account, there may be a little line on your explanation of benefits that outlines the reasons the claim was denied and then, patient not liable. This can often be the case if your doctor did not obtain an authorization, referral or performed a restricted services (like an annual physical) outside of the allowed time frame. If you receive a bill and your insurance explanation of benefits says “patient not liable” bring it up with your doctor’s office.
3. If you’re uninsured, negotiate! Remember when I said we aren’t paid our billed amounts by the insurance company? Well, as a self pay patient, there is a good chance you’re paying the full billed price, unless your office is already giving a self-pay discount, which we do in our office. If you’re self pay, don’t be afraid to ask for discounts, a lot of the time the office will work with you. Throw at them that you know the insurance payments they receive aren’t their billed amount.
Next time you get a confusing medical bill in the mail, hopefully something above will help! Keep in mind, everything above applies to commercial insurance only. Medicare/Medicaid comes with its own set of rules. Also, in some offices you may sign a document that protects the office in some way from eating the cost of non-covered services. So, keep in mind, this information may not apply to your particular situation, but hopefully it will give you a starting point if you’re hit with a confusing bill.