Medical Insurance Hassles
Another medical bill......
Having worked in the medical field for over eight years, I have worked through just about every aspect of the medical insurance run-a-round. With insurance guidelines changing, government policies amending and medical technology becoming more advanced , the customer is getting more confused when it comes to the medical bill they receive . It used to be when a patient would call me about their doctor’s bill, I could clearly explain it in 30 seconds or less, the patient would be satisfied and pay their bill without hesitation. However, once time had gone by, the medical claim process got more complicated, patients policies had more limitations, and there was more complaints than ever before. So why all the confusion? It should be very easy. Patient sees the doctor for medical services, pays their co-pay, the doctor's office files the medical claim, and then gets paid. Unfortunally, some of the medical claims don’t process that easily.
So what can the customer do to avoid the common medical insurance hassles? The following tips may make it easier for you to understand your medical bills and provide solutions for those common problems with claims.
1. When you get your medical policy, make sure you take the time to read it carefully. Many insurances have restrictions like pre-existing conditions, limited coverage for certain procedures and no coverage for certain medical conditions. You should be familiar with how much deductible you have to meet every year and know how much you catastrophic cap is. If you have any questions regarding ANYTHING in your policy you should always contact your medical insurance carrier, not the doctor’s office or hospital, they will not know the specifics of your policy.
2. When you receive your medical insurance card, even if it is just an updated one that was mailed to you, always check to make sure all the names on the cards are spelled correctly. A misspelled name will almost always cause a denial or delay of processing your medical claim. Also call the insurance company to verify the date of birth of every one who is covered under that policy, wrong date of births can also cause a denial or delay in processing a medical claim.
3. If you are receiving a new medical insurance card make sure you immediately give it to your doctors office so they can make a copy, even if the ID # is the same as it always has been, there may be changes to the card that you do not notice. The most common change I have seen is the mailing address to send the medical claim changes or the EDI # for which is used to file the medical claim electronically changes. In this case the patient could receive a bill simply because the insurance company did not receive the claim. Also insurance plans can update often and your group number may change. If the correct group number is not used, the claim may come back denied as patients coverage has terminated.
4. The customer should be aware of the Coordination of benefits rule. What this means is the rules that apply when you or your family is covered under two or more health insurances at the same time. Make sure you check with the insurance companies to find out which one you have to use as your first insurance (primary) and which to use as your second insurance(secondary). Please understand that you CANNOT CHOOSE which one you want to be first or decide not to use one at all by not showing the insurance card at all when you see the doctor, many have done this and it costs them a lot of unnecessary financial burden. For example, you know that your primary insurance is an HMO and the doctor you want to see does not participate with your HMO insurance, so you decide to use your secondary insurance. You figure it is not going to matter and they participate with the doctor you want to see. You see the doctor and just give them your secondary card , they file the claim and get paid. Thinking everything is okay, you go to that doctor for a year that way, but eventually your primary insurance finds out that you violated the Coordination of Benefits rule and requests all the money back which had been paid to the doctors office. Now you are getting a bill of over a thousand dollars because you tried to get away with using just one insurance of your choice. You will owe that money. Another tip is if your primary insurance is terminated, you must notify your secondary insurance and provide the cancellation of benefits paperwork to them so they can update your insurance information in their system. Secondary insurances usually don’t magically know that your primary coverage has terminated, so it is your responsibility to provide that information, or medical claims will be denied saying bill primary insurance first. It lessens the medical insurance headache.
5. DON’T IGNORE MEDICAL BILLS. I cannot stress this enough. Some patients who get a medical bill immediately get frustrated and angry. “Why do I have to pay this, I already have enough taken out of my check! I paid my co-pay, now they are saying I owe $ 135.00, this is ridiculous, I am not paying anything” and the bill gets tossed in the trash or patients simply do not understand the bill, so they rip it up. Sometimes I had patients who did not challenge the bill when they received it and when I tried to collect the overdue balances at time of service, they told me they thought it was a mistake and that their insurance should of taken care of it. This kind of attitude is avoiding the issue, and may limit your appeal rights. When you receive a medical statement feel free to ask questions and an explanation of why you owe the money, also read your own medical EOB (explanation of Benefits), this should be mailed to you before you even get a bill. If you do not receive one ask your insurance company to provide you with one and if you have the internet you may be able to sign up to have access to your medical insurance information. Sometimes the doctors office may be able to provide you a copy of your explanation of benefits, however if the statements are batched with other patients claims, you will not be permitted to have it due to the HIPAA privacy act.
6. Build a Rapport with the Doctor’s office staff. The more you know the staff and build a rapport the better it will be to solve problems when they arise. For example you have a new medical insurance and the medical assistant draws your blood, she sends it out to Quest Diagnostics lab which is not a contracted lab with your new policy . The medical assistant knew it had to be sent to Lab Corp, but it was a hectic day and she overlooked it. About a month later you receive a bill in the mail for $ 250.00, you call your medical insurance carrier and ask them what is going on. They tell you that they are not contracted with that lab where services were rendered and you are responsible to pay it. This has happened to me before and I know that the patient should not be responsible because they had shown me the new insurance card with the Lab Corp logo on it which tells me that is the contracted lab the patient must use. A good rapport is important because in this case sometimes something can be done. The doctors office usually has a lab account rep they work with who’s job is to help solve client problems, if the staff can admit an error was made on their part and the patient was not at fault, there is a chance (not a guarantee), that the company will write off those charges, sparing the patient from owing the balance. Always be kind to the person you talk to and be patient with them. Now on the other hand if the insurance card did not have any indication of what lab to use and the patient did not provide that information, the patient may be responsible to pay it. In the end it is ALWAYS the responsibility of the patient to know their policy and inform the medical staff of any changes or limitations.
7. Be on the lookout for billing errors: In this day and age with all the technology you would think that billing errors are the thing of the past, actually billing errors are still quite common. One common mistake is being billed for a procedure you never had done. For example, an honest mistake where the doctor wants you to have a urine dipstick test done. You get the urine specimen cup, but for some reason cannot provide a sample. At this point the urine dipstick test was never completed, but the doctor failed to remove the procedure from the billing page and it gets billed . You get your statement and realize the test was never done, in this case it would be reasonable to call the doctor’s office to explain the situation. The staff will check your medical record for verification because there should be documentation in the patients record stating why the urine test was not done. The doctors office should contact your insurance so they can submit a new corrected claim. Follow up with your medical insurance to make sure this has been done, it is required that medical staff contact the patients medical insurance carrier if any billing error has occurred. They should also send you a new statement reflecting the billing changes.
Some other common billing errors include:
- Invalid diagnosis code
- Invalid procedure modifier
- Misspelling of a patients name or wrong date of birth
- Billing the claim under the wrong patient
- Not filing the correct insurance
- Using a wrong NPI# (National Provider Identification number)
The purpose of this article is to provide useful information to the consumer, it does not, in anyway guarantee anything. There are a lot of different factors in any billing dispute case and if you are unsure of any medical bill you should contact your medical insurance company first, then the medical billing department, in some cases you may have to contact your Human Resources Department at your work to get a problem resolved.