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.
-Brooke
My husband worked with hospitals for billing management softwares so he’s definitely the one that takes a closer look at any medical bills! xo, Biana –BlovedBoston
I just noticed a billing error last week, so ironic that I read this post this morning!
Christina :: Simple and Delish
These are helpful tips! I’m navigating so many medical bills right now it’s hard to keep track but it’s definitely worth double checking everything!
Jill
Doused In Pink
Great post! I have some dental bills that I need to look at to make sure they were put through correctly. Bleh! Dental work is never cheap!
Carrie
curlycraftymom.com
Insurance is seriously so confusing! And I’ve been in a situation where a certain procedure would be covered, but only if a certain diagnosis code was used. The doctor wouldn’t use a perfectly acceptable different diagnosis code so I ended up leaving and going to a different doctor who would. So knowing both procedure and ICD-10 diagnosis codes are important! Thank you for these tips! I had no idea you could potentially negotiate a self-pay (if there is a procedure insurance won’t cover).
That’s for sure!
Definitely worth a double check, you never know what may be a mistake 🙂
How funny! It happens so often, I always tell my friends and family to double, double check!
That’s awesome!!
Wow! I can’t believe your doc wouldn’t resubmit with the right ICD 10, that’s just crazy. Good thing you switched!
Thi is such an insightful post and one that is certainly beneficial to everyone! Thanks for breaking this all down, making more sense of some of the questions that I often had. I hope you’re having a wonderful start to your week so far!
XO,
Jalisa
http://www.thestylecontour.com
Such a helpful post. Thank you for sharing this.
Good post! Medical bills are horrible to try to understand and the worst part is, they are so frequently incorrect! Thanks for the advice.
Nineteen
Windsor
so so so thankful I live in Canada and don’t have to worry about this, I don’t know how you guys do it.
Simply Shaunacey
Such great tips…thank you!!!!
Laura
http://www.blackcoffeebeautiful.com
Posts like this are so helpful to so many people! I live in Canada so things are a bit different here but a lot of it still applies. I am guilty of not having my benefits details memorized and I never remember what’s covered or how much! It’s definitely something I need to look into.
Evelina @ Fortunate House
Oh my goodness! The frustration I have with medical bills! Bless you for dealing with that on a daily basis. Trying to figure out medical insurance is like trying to read Chinese. I. Just. Cannot.
Thanks for the advice.
Traci
waltzmetoheaven.com
This is such great advice! Thinks have changed so much just in the past 3 years. So good that know!!!
Xoxo,
Whitney & Blaire
Peaches In A Pod
Totally agree- medical bills are in a different language! This was easy to follow + very informative. 🙂 Thanks for sharing, lady!
-Ashley
Le Stylo Rouge
Such a helpful post! I’m Canadian so there are differences but some things still apply especially when it comes to insurance & I’m the worst at knowing what my benefits are or what my exact coverage is so this is a good reminder!
Marta
http://www.sweatersstripesandsweets.com
This is such an informative post! I never understand why i’m still billed so much even after insurance covers a portion, but this will help me out tons especially since I’m about to be off my parents’ insurance soon 🙁 (I don’t want to be an adult anymore)
Raven
http://simplesassysultry.com/12-essential-spring-pieces/
Since we own a small business, our health insurance isn’t very good. I found that calling the medical provider to negotiate a better price often works. Great tips!
These are helpful tips. I get really overwhelmed when it comes to dealing with insurance and medical bills, but this is great advice. I need to really look at my policy and see exactly what I’m covered for.
I hope you find some help in Jalisa! Thanks for your kind words. 🙂
You’re welcome!! Thanks for reading. 🙂
So true!!
I would love to know what it’s like in Canada, in America it is a near disaster!
You’re welcome! 🙂
Most people don’t, I’m not sure how it is in Canada, but here it is so complicated it’s almost impossible to know what your benefits will be for what you need.
I just fell into it, but goodness it is a headache!! Luckily, I’ve been dealing with it for so long now, I’ve learned my way around lol
Thanks girl! So many big confusing changes!
Thanks Ashley!
I would love to see how Canadians are handling their healthcare, we could learn a thing or two!
You’re not alone, that is the top question I’m asked by patients all the time!
Good for you!! I feel for you having to cover your own insurance, not cheap and then your out of pockets are high on top of that!
Thanks Shea! Insurance is overwhelming, even after all these years, it’s hard to keep up with the changes and I’m always having to ask questions!