Medical Billing

[creditdodger]

There are a few things that I learned while I worked in the medical billing field. I will try to cover the stuff that as a consumer I make a point to follow.

This is all based on the presence of Insurance. But others without can also benefit.

Never pay a doctor or hospital anything before first checking with your insurance. They will provide you with an "Explanation of Benefits". On the EOB will appear the way the claim was paid and the patients responsability. If you don't understand the EOB call the customer service line and ask what your responsability is. If it sounds a high, ask why. It may have been processed incorrectly. We had a track record of processing claims incorrectly about 5% of the time. They can only get corrected if the patient calls in.

I saw many cases where the provider would be underpaid and instead of checking with the insurance co., they simply bill the patient for the difference. When really it is the insurance's responsability to pay.

There is also the case where the provider "feels" that they were underpaid, and bill the patient, even if they have been paid in full by the insurance company. This will usually happen when the provider is a "network provider". This means they have a contract with the insurance co. in which they agree to give patients of the ins co a discount, sometimes as much as 50%. This is sometimes not known to the poor medical biller who is expecting a whole lot more. When they only receive half, they figure that the remainder will be the patients responsability. But this is breach of contract and your insurance company is your best asset to set the provider straight. We had an entire department dedicated to go after these shady providers that would try to make an extra buck. Some of my favorite times were when I had to call these providers and threaten to sue them for breach of contract and get their licenses revoked with the state. Of course, they were always "billing mistakes" and would be corrected right away.

It would break my heart when poor unsuspecting beneficiaries (bene's) would call and tell us the horror stories of these collectors. I really enjoyed putting the smackdown on these losers.

An easy indication of something going wrong with your medical claim is never receiving your EOB. If you get a bill and not an EOB, something is wrong. Do not pay. You are probably paying a pretty penny for the coverage and you are entitled to use it.

Every insurance company has guidelines in how providers bill the claim to the insurer. If it does not meet the guidelines, the insurer has the right to send it back. It has not been denied, simply needs to be corrected. But again we have lazy billers who simply put the balance in the patients column when it was their fault for not getting paid.

I will try to answer any other ??? you might have.

[momof5]

Gotta love it!

I had a CA actually tell me 2 days ago that the medical bill would not have gone to collections if I didn't owe it! LOL I told her that the INS CO paid an agreed amount and I did not owe the difference. (Actually, they called for my son who is 17. I informed them that he is a minor. Yes, I am mom. What is my name? LOL!!!! If they don't have that, then they can't get me! C&D went next!)

[creditdodger]

I cannot stress enough...Save your EOB's. At least 7 years. This is your best protection against the CA and Medical Providers.

[reno2360]

What a great post. All correct.

I just wanted to comment on that the medical billers job is to know the contracts and there is no excuse for them to bill the patient when the contract says they can't.

[katwoman]

Creditdodger......

Thanks for the post. It's always great when someone comes to the boards with firsthand knowledge of such workings and is willing to share that knowledge.

Question: In my dealings with various medical entities in regards to their collections practises, I've come across gross differences in what is considered a properly aged account. For instance, one medical biller will start the clock ticking after 2 attempts have been made to get the insurer to pay. They then bill the patient at 30, 60 and 90 days whereupon it then goes to a CA. Another medical biller starts the clock right away. Doesn't matter if insurance is pending or not. Yet another biller will go as long as a year waiting for insurance to cough up the $ and is loathe to send the bill out to a CA.

I can't believe that there is no standard!

I'm in IL, if that matters. Please clarify all of this for me.

[morrow]

In our office (Optomotrist), when a patient calls or comes in to set up an appt, we verify thier insurance info, then we call the ins. company and get a breakdown of thier exam/hardware coverage/Co-pays? ect. We do this as a courtesy to the pt. and because almost 100% of the time they have no clue what is/isnt covered. IF FOR SOME REASON A PATIENT IS NOT COVERED, WE ALWAYS CALL THEM TO INFORM THEM AHEAD OF TIME, that way they arent suprised when they come in and realize that they need to shell out $190 for an eye exam.

It completely baffles me that most people are not aware what thier insurance covers or what type of bennys they have. Ive even had several people not know what ins co. they have.