What you don’t know about your insurance costs you…

Darn near every day I come across a situation where an insurance claim is denied by the insurance company in error.  Now a lot of hospitals just toss their hands in the air and go “Oh well, bill ‘em.” but at my office they have me to follow up.

Why is this important?  I also run across people whom we bill to get their attention who then either pay their bill or ignore it until we can no longer collect from their insurance company and they go to collections.  My mom and dad did that with many of their medical bills, not realizing they were screwing themselves out of money.  So here it is, the need to knows of your insurance and medical bills.

1) Don’t expect your doctor’s office or hospital to know if they are in your network. Every insurance company has many different plans.  Employers are able to pick and choose what is included in a plan, to a point.  Just because your buddy has United Health Care and sees Dr. Jones doesn’t mean your United Health Care covers the same doctor.

Doctors are also credentialed by where the services are covered.  So if you see Dr. Smith at 1234 Main St. Way and it’s covered doesn’t mean you can see him at 4321 Second Blvd. Ave.  He might not be credentialed there.

Most medical offices and hospitals do a verification of benefits but don’t count on them doing it or telling you if your out of network.  You have the right to see an out of network doctor, paying the full fees of course.  Call your insurance company before you make an appointment.  Make sure they know which doctor you are seeing and where.

2) Know your benefits. This is sort of like number 1 there but know if your insurance covers an epidural or that leg brace.  It may not.

3) Answer letters. A lot of insurance companies mail letters to their members on a regular basis.  Often times they are making sure you have no other insurance coverage or that you (or your child) is still in school if they are over the age of 18.  Answer them.  Call the customer service line and get a fax number then fax your response and keep that fax receipt showing it went though.  Until you answer them the hospital and doctor’s office can and will bill you the full amount of their service.  If you do not answer them in a timely manner they may deny the claim leaving you to foot the bill.

4) Get names and reference numbers. If you have to call your insurance to follow up on a claim get the person’s name and a reference number for your call.  If you need to follow up again you’ll have it.  Also, call the billing department and give them that information as well.

5) Ask the right questions. Ask when a claim was billed, what the CPT code was (that’s the code telling the insurance what the doctor is charging for).  Get the reasons for a denial.  Was an authorization missed?  Who was responsible to obtain that, you or the doctor’s office?  What information exactly are they missing?  Ask questions until you understand what they are telling you.

6) Don’t just take their word. The customer call center people are notorious for giving their members bad information like they don’t have a claim on file or that the doctor’s office or hospital messed up.  Call the billing department and find out why they were told a claim was denied.

7) Know how to read your EOB (Explanation of Benefits). Do you know what a contractual discount is?  What about a network discount?  What about a global code? If you don’t call your insurance company and have a rep go through an EOB with you.

8 ) It’s ok to take it to a higher power. Insurance company giving you the run around?  Or is it the billing office?  Don’t be afraid to enlist your doctor to help you.

9) You are the customer, to both parties. Your company (or your policy holder) and by extension you, is the insurance companies customer.  If you feel that you aren’t being helped by them call your HR rep and voice your opinion.  If enough people do this the company may shop elsewhere for better service.  Dirt cheap coverage isn’t any good if you still have to pay claims because they won’t when they should.

You are also the doctor’s customer.  While it can be daunting to argue or question  something with them don’t be afraid to ask them to clarify why you were charged for X, Y or Z.

10) Your doctor/hospital has a contract with your insurance company. This contract spells out what they can charge you for a service.  If you think your being charged for something they shouldn’t charge you for call your insurance company.  Honest mistakes are made by billing department/groups but if you don’t make a call or two to find out if you are supposed to pay something then the assumption is that you do if it goes to collections.

11) Keep your receipts. When you make a payment to an office, by check , credit card or cash, keep a receipt.  Payments can get lost but if the doctor’s office/hospital can’t find they payment it’s up to you to prove you’ve paid it.  If you can’t they will keep billing you.

12) Know about self-pay discounts. Sometimes a doctor isn’t in your plan, or something isn’t covered by your insurance (like a Chiropractor).  Ask them if they have a self-pay discount.  Generally it will be the average price of what an insurance company would pay for the service.

13 ) Know how to do a written appeal. Sometimes the doctor’s office/hospital just can’t help you fix a claim.  If that happens know how to do a written appeal.  Some things to keep in mind, know if your policy has a “reasonable person clause.”  Most policies have them.  What it means if is a reasonable person may think something could be an emergency (like having a headache of a 9 on the pain scale for 12 or more hours) then the quest for care or test was prudent.  If you appeal to that and have good showing to prove it then your claim will most likely be paid.  Remember let the billing people know you are appealing the claim.

When writing the appeal you should be to the point, not emotional and have names and dates.  If you called your insurance on the 14th and they told you Dr. Mike was in network, then your doctor’s office called and was also told that Dr. Mike was in network but it turns out that Dr. Mike isn’t in network but Dr. C. Mike is then you need to be able to show you put due diligence into avoiding an out of network claim.
Understand the appeal may still be denied but the doctor’s office/hospital will most likely give you a self-pay discount.  Ask them but keep in mind they are not under an obligation to not bill you until the issue is resolved, you will probably have to make payments until the insurance company pays.

Some Kyle, some geek, some work

Some Kyle:

Kyle has learned to crawl.  Actual crawl, not the frog hop, drop and drag worm thing he’d been doing for a month now.  His arms and legs are still a little unsure of what’s going on and it’s slow, but it’s a crawl.  He can’t even sit up yet without flopping over.  That isn’t important to him, sit!  Bah on that!  I must move!

Some geek:

Jason may have it in him to run a new game.  Right now he’s not sure and he’s not decided if it’s VtM or a Spycraft game, but it’s a game.  Dear Gawd it’s a game.  Paul’s on board, B’s on borad and Greg probably will be.  A real game after all these long, dry years.  Time with friends!  Rolling dice! (Dear Gawd I have to find mine).  A game, a game, a game!

Of course the mom in me went “Those dice have a tendency to get lost and are the size of a baby windpipe.  We need to make sure they are all picked up all the time.”

Some work:
The sheer number of people who do not understand their insurance and how a doctor’s bill works astounds me.  The number of people who ignore letters from their insurance company telling them they won’t pay a claim until they do X is staggering.  The sheer balls on those same people to call me up and rip me a new one when we have the audacity to actually bill them for their treatment is mind boggling.

You go to a doctor.  As a courtesy they bill your insurance company on your behalf.  They don’t have too.  They can tell you you get to deal with the headaches of getting them to cough up a check.  If they don’t pay, you have too.  It is your bill.  Every day I work as hard as I can to get your bill paid, but sometimes you actually do have to pay.

It’s been a while

Yeah, it’s been a while since I updated this blog.  Not because nothing has been going on but because by the time I can sit on my computer I want to mow down little elves bowling and then go to bed.

Two weeks ago I started a new job.  It’s a good job, medical billing.  I’m following up on unpaid insurance claims and I’m damn good at it.  So far my boss is impressed by how I jumped in and ran with the ball and how I’m actually getting some issues resolved.  Seems the two people who did it before me wouldn’t do anything if it looked complicated they’d just rebill it and rebill it and ignore it.  Sadly I’m looking at an account now that we will probably have to eat about 4k on.  Stuff like that pisses me off.

It’s a 40 hour a week gig.  It’s not going over well on my fibro though.  So far I’m dealing with it ok and I’m going to be going to my doctor to see about the new meds they have on the market.  Just to give you an idea how of often I actually take prescriptions, I found one, with only 4 pills gone, that had a date on it of 2005.  I figure once I start walking that path it becomes almost impossible to step off of it and for the most part I can manage things with over the counter stuff and rest and exercise.  Yes, I’m exercising.  Well, putting Kyle in his stroller and walking but that is exercise.

Tonight Jason and I have a meeting and Church to officially become members.  He was a member but because he went inactive they removed him.  I was a member at another church years ago but like many 20 somethings I got ambivalent about going.  I went through a period where I never stopped believing in God but stopped believing in Church.  In recent years I began to become interested in making it part of our lives again and when I had Kyle that corked it.  My parents never went on a regular basis so I grew up only going sporadically and I don’t want that for my son.  Jason grew up with a father who seemed to feel that you had to go to Church but it was an obligation and a chore.  He also seems to have used his Catholicism against his kids and his ex wife.  As if a man who hides his assets to screw his ex over is a real Christian.  But he was one of “those”.  At least from what I can gather.  Jason almost never speaks of his father but when he does it’s in pretty negative terms.

And in some ways I’m sort of glad his father was such a shithead.  Unlike some kids who grow up with one parental figure who checks out, Jason is hell bent on not being his dad.  And is probably way more interested in doing things with his son because he wants too, not because he feels it’s it’s fatherly obligation.

Anyway, it’s birthday month here.  My mom, dad, sister and my two eldest nieces all have birthday’s this month.  So happy birthday to them all!

Kyle has started solid foods!  At first I thought perhaps he was ready physically but not emotionally.  He fought, he spit and he made the Mr. Poison face.  But on the third night he was screaming at me if I didn’t shovel it in fast enough for him and stretching forward to meet the spoon with his face.  So far he just loves his rice cereal mixed with apple juice, he’s ok with banana’s and he seems to enjoy carrots.

It’s funny because he looks so much like me and my dad and his family.  This was something we never expected in a million years.  Yeah he might look like me but he’s his daddy in expression and personality.  He’s so laid back and easy going and such a boy.  He likes it when you bounce him, I put him on my bed and brace my arms around him and go “Bounce! BOUNCE!” and he just smiles so big.  He likes being dirty, enjoys to play flying baby and all these other ‘rough’ games.  He’s as generally happy as his daddy is and eats like his daddy too.  Talk about a baby who seems to have gotten the best of his mom and dad.  Now don’t get me wrong, my husband is hot but Jason’s personality is by far the thing I love most about him.  His pleasant, easy going, go with the flow.

While I would never consider my self hot or even overly pretty if I had to choose Kyle looking like me or having my personality, I’d choose looks hands down.  I’m over emotional, obsessive, retentive and given to periods of depression and deep self doubt.  So when I say he’s got the best of us I’m really saying God reached in and helped us make a son who is the best reflection of his mom and dad.

He’s also discovered getting onto his hands and knees, and my father swears he took two crawls forward the other day.  Lord help us.  He’s already inch worming across the floor and chewing on daddy’s XBox controller cord is a favorite pass time for him.  When he starts to actually crawl I have a feeling that he’s going to be one of those kids who will find everything, destroy everything and claim everything as his.  I’ve said it many times but I’ll say it again, I have a feeling our toddler years will be loads of fun.