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Are You being charged properly By Your Doctor?

Updated on May 7, 2015
Kimberlu profile image

I have 25 yrs. exp. as a Medical Billing & Collection Consultant and a Personal Injury Paralegal & I am writing a book & movie Script.

Know Your Medical Insurance

Most Doctor's will try to charge you the full amount of your deductible the first time you are seen under your insurance. Most people will just pay whatever the doctor's office says to pay just to get it out of the way, Don't do that anymore know your rights and what you will actually owe.

Do you know?

How well do you know your Insurance Plan?

Do you Know what your co-pay, co-insurances and Decutables are?

Do you know what your total out of pocket is per year?

Do you know when your deducatable starts and end?

Do your Medical Bills Match what the insurance company sends you?

Do your Medicare bills match your medical bills or did they bill your secondary insurance?

If you so not know the question to all of these questions and more then please read on, you will be surprised at how much you may end up saving.

Knowing your Health Plan

First get to know how your health plan coverage works. You are provided with a book every year from your insurance company letting you know what is covered and what's not.

I have worked in the Medical field for over 20 years and the one thing that amazes me the majority of patients do not read their coverage books. I decided years ago to become a patient advocate and explain how the insurance works and how to choose the plan best for you and your family.

The most important thing for you to know is how your insurance works and the terminology your Doctors biller will use.

The Diffrence between Co- pay, Co-insurance, Deductables and max out of pocket.

1. Your co-pay is applied to your office visits and with most insurance companies your deductible will not apply to your deductible always check to make sure. If you are unsure then call your insurances customer service.

2. Deductibles can either go from Jan to December or July to July it is important to ask your insurance company when you deductible starts and ends.

3. Deductables are applied to such things as blood work, x-rays, hospital stays and other testing.

4. Once you have met your deductible your co-insurance will start, a co-insurance can be 10% , 20% etc of what the Insurance will allow for payment. Like your deductable these apply to the same services. Always get a receipt no matter what. A receipt with the Doctor or Providers name on it holds a lot of weight and you should always attach it to your bill and your EOB.

5. If your maximum out of pocket is $ 2,000.00 and you Deductable is $ 250.00 these could be applied either individually or total for family per year. It is important to know this and important to know when it begins and when it has been met. So contact your insurance and ask them where you are at with meeting your out of pocket expenses let your Doctors office know that you have met the out of pocket and you wont have to pay till your plan starts over make sure they note this in their computer and watch your EOBS to make sure you are not being charged.

6. Your bill from your Doctors office should match your exlaination of benifits or what your biller will call an EOB. Know how to read them and always keep them together so you can always make sure you have a check in balance with the insurance and the doctor. Your payment will always be a percentage of what the Insurance says is the allowable. If your doctor's office tries to charge more that is when you tell them that is not what your EOB says and have them pull it out so they can see it too.

Recentely I had a third time cancer patient call me and ask if I would be willing to fly to california so I can look at their medical bills. The client said that their deductable was $ 300.00 per person and that the maximum out of pocket was $ 2,000.00. Their bill from one Doctor was $ 5,000.00. I agreed to fly to California and to find out what was going on and meet with the billing manager and get the bill corrected.

Before I go further in my story I would like to tell you what my credentials are I have already told you how many years I have as a Medical Billing Manager and Office Manger , I also have held a Certificate of Parlegalism for the last 20 years.

I arrived in california and started going through the bills I found over $ 4,500.00 in billing errors. First the patients Insurance Period runs from July to July second the patient had been hospitalized 2 times, had 4 Doctors, Had 3 Pet scans which are what they use to find tumors on a cancer patient and he had a few months of chemo therapy.

I looked at the patient and said hmmm I think we have a problem here and it isn't a little problem. With all the Doctors he had seen and the tests, chemo and the hospital there was no way he could have that high of a bill with one Doctor.

The first thing I found was that the billing department had duplicate billing they had charged twice for the patients bone marrow on the same day. Second I found charges for injections that the insurance had said were not covered or payable and the Doctor office was to write them off. Thrid the patient was paying a co-pay of $ 30.00 for each visit and the insurance was saying that the co-pay was only $ 15.00 for the visit. The billing department was not posting all the co-pays.

I called the Billing Manager to arrange a meeting and I requested a copy of what is called a billing ledger that shows where all the monies are posted and the charges. Much to my surprise the ledger was reduced to $ 1,500.00 what the Billing Manager had done was fixed the duplicate billing for the Bone Marrow and had money on the account that she had posted. Now by this time I had spent five days working on a spread sheet to take to the Billing manager to show her what was wrrong.

I was aggravated because I had to start over so what I did was go through the ledger and high light everything that was wrong. When I met with the Manager she had no idea what my credentials were she just thought I was helping out. She tried to B/S me so I pulled out the big guns and let her know that she could not play games with me because I knew what I was talking about I let her know that she had 48 hours to correct the bill and showed her what needed to be fixed.

Now pulling out the big guns was letting her know what my credentials were and that the office was in very big trouble because they had commited fraud by the duplicate billing and not writing off the things that were to be taken off per the insurance.

Why would I say fraud if a Doctors office puts a statement in the mail that is not correct it then becomes a legal document. Next by not following the insurance EOB it then becomes fraud. All guidlines have to be followed. The patients bill was now about $ 300.00.

If you are a patient and you think that you have a billing issue please make sure that you match your bills look for things that do not look correct and make sure you call the office on it. Make sure that you know when you have met your deductable and your out of pocket. Always keep a record of who you talked and the date. You also want to make sure that you keep all your envelopes and attach them to the statement incase there is an issue.

If you have a a problem with your billing you have options to resolve them if you can not resolve them with the biller you send a confidential letter to the Doctor first if that doesn't work you contact your insurance company or Medicare and let them know the areas you are having. The next level would be to contact the OIG which you can find on line or one of the following links:

I also want to point out that that if you are a patient that is experiencing a financial burden and are unable to pay the bill you may ask the office if they have a form that they would like you to sign or if you should send a letter stating that you are unable to pay the bill because you have been laid off or have a limited income at which time they will have to write off the balance of the bill. Please only do this if you have a realy financial burden.

People think Doctors make a lot of money today they can barely cover their payrol and supplies where as ten years ago they where making money Doctors have been hit just like all of us with the recession so if you can pay or need to make payment plans then please try to do so.

Another thing I want to point out to you is the HIPPA law. When I went into speak to this office manager she wanted me to have the conersation in front of other patients and that is completely against the HIPPA privacy Law. If you should be in a Dr. office and they want to talk to you about personal information you have the right to ask for a private conversation. I would alert if this should happen. This is a serious matter your privacy no one can aske you for your phone number, address or social in a room full of people.

I hope this has helped you and if you would like more information you are welcome to contact me and I will be happy to help you with what your issue is.

Don't let the insurance company or the Doctor run over you.


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