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.


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