Medical Collection? Read This First

[retmar]

Since I've been a member, I've noticed that most everyone, including myself in the beginning, never checked with our insurance carriers prior to asking questions about a medical collection. I am going to share what I learned in my quest, several items the majority of patients and/or beneficiaries do not realize is available to them from their insurance carriers. If you wonder why I say this, the answer is that the majority of us never read our handbooks when we received them. All we did was throw them in a drawer.

You must also realize that many medical providers do not handle their own billing. They contract out to billing companies, and, too many times the "reps" have no knowledge of all they should have knowledge of. As to the ones who do their own billing, too many times they let items "slip" past them. Plus, they never pay attention to the fact that the Doctor may have not allowed you to work for a period of time, so assign debt when not paid in a timely manner.

The following are items you must have knowledge of before approaching a CA about a debt allegedly owed by you. Also, to the many who have just agreed to pay, you may have paid too much.

1. When a medical provider agrees to accept assignment from a patient/beneficiary, they are agreeing to abide by all rules and regulations in the agreement. This is one reason you will find providers who do not accept assignment. They want to be in charge of their money.

2. A patient/beneficiary is never liable for any amount not noted as a patient responsibility, copay, or cost share.

3. A patient/beneficiary is never liable for any amount other than the "allowed amount" if claim is denied by carrier. This usually occurs if your deductible has not been met. Since your deductible has not been met, the carrier will deny payment for this reason and apply the allowed amount to your deductible. You are only liable for the allowed amount. How this works is like this. The provider bills for $500, the allowed amount is only $150, this is all you pay. If the provider tries to cause you to pay any amount over, including the amount billed, this is called balance billing and is illegal under Federal statute.

4. A patient/beneficiary is never liable for any amount considered "mutually exclusive". The provider can bill, but, must write off as a loss. This particular item is most always found on an emergency room bill if treated during a designated time, such as between 10 PM and 6 AM.

5. A patient/beneficiary is never liable for any noncovered treatment unless certain steps, set by carrier, are taken. An example of this is some carriers require the provider to explain this and have you sign prior to treatment. If they fail to follow proper procedure, they must write off.

6. The patient/beneficiary will treat the EOB (Explanation of Benefits) from their carrier as their proof of any amounts due. If not on the EOB, you are not liable.

7. If a claim is denied for some reason other than deductible not met, it is the sole responsibility of the provider to respond in kind for proper processing and payment. An example is if deneid as there may be another carrier who may be primary. The provider must obtain the info and resubmit claim with it. If they fail to do this in the within the time allowed, they must write off.

8. If a provider fails to file their claim within the time allowed by insurance carriers for filing, they must write off. Most times are one year from date of treatment.

Most important, before you do anything else, contact your carrier. If you do not know the date(s), and have your CR, use the oldest date shown as it will usually refer to the date just following date the EOB was processed, or the date of service, or the original amount claimed by CA, no interest or fees added. Or, give the rep the name of the provider as they have a screen avaiable to them to find the one you need. If an older debt, they may have to go into their archives to locate. Do not be afraid of your carrier as they want to know if a provider is playing games. Also, some carriers have a special department for this problem. Yes, mine is the US Government due to my being retired from the military, but, once I contacted them, I had to do nothing else. They took over, and all was handled within a couple of weeks. They sent us a copy of each piece of correspondence. True, I was involved regarding our filing of a complaint with the CA's, but, nothing else.

Regarding violations of HIPAA, one must realize that when you sign the paper, such as in an ER, you have somewhat signed away your rights. To claim a violation, the burden of proof is on you and it is very difficult to prove. The provider and/or CA will most always be able to get around it. Yes, many times an agent of a CA will call their "buddy" in the billing office to learn what the codes refer to, if supplied on assignment. Can you prove it?

Lastly, any of you who can add to this, please, without hesitation, add it so all can be aware. Do realize I am asking "Admin" to make this a sticky so it will be available at all times for future members. As to why I started this, the reason is to save space. If you pore through the site, you will find several threads asking the same questions about medical bills. Now, it is right here on Page 1 to be read. Then, once the member has read, they can do their part, then pose questions not covered or are still confusing to them. Please do not load this thread up with questions, let's just keep it small with helpful information we have all learned or have knowledge of.

[retmar]

After rereading this information, I noticed I forgot to include something that is most important. This information is what my health insurance carrier has in their rules and regulations. My carrier is Tricare, the health insurance coverage for our active duty and retired military personnel, as well as their families. Yes, I am retired from the military as I was retired from the US Marine Corps for wounds received in Vietnam in 1969.

What I want everyone to fully understand about this is that your health insurance carrier may or may not have the same protections, or, they may have a variation in effect. This is why I cannot stress enough to all of you to call your health insurance carrier first before anything else. Remember, you pay enough for the coverage, use it.

[LadynRed]

Excellent points Retmar !

I'd like to add a couple of comments here, maybe it will deflect some collections before they become collections.

Even though medical providers file claims 'for' us, YOU, the Patient, are ultimately responsible for the bill. It is VERY important that you examine EVERY single detail of the EOB's you get and if you have any questions, call the provider and call the insurance company. Mis-coded procedures are a huge source of denials, so always follow-up on any denials. DO NOT RELY on JUST your medical provider to push things for you. YOU must stay on top of it. I know - we all lead busy lives, but this is one place where you really must be a stickler and stay on it.

If you don't get an EOB within a week or 2 of your dr visit, call the Dr's office, call the insurance carrier and find out why.

[Methuss]

How about if a provider (hospital) farms out work to an out of network 3rd party lab after you have specifically informed the provider that they must use only in-network services?

[dpgirl]

Methuss,

I had that same issue and unfortunately had to fight tooth and nail with my insurance company. My insurance is through my employer and this question was asked when the rep came out and explained the plans. We were assured that if one of us was to present to a hospital via ER or scheduled surgery or for whatever reason that any bill associated with that visit would be paid at the preferred/contracted rate. This would cover any labs sent out, ER doctors, doctors called in for a consult, etc.. as the patient DOES NOT have any control over whether the ER MD on call is contracted or not. That goes with labs, x-ray interpretation and so forth. We were assured that if we went to a contracted hospital any charges associated would be processed as in network and contracted.

However, when the claim is presented to the insurance company for processing it seems to be another matter. It was my experience that I had to speak to customer service and educate them to this fact. I made them look up MY benefits and check, I knew I was right. If this insurance is through an employer it may be possible to have someone from Human Resources intervene. Anyway, good luck and just keep on them until they get it right.

[retmar]

Good point, Methuss. This is why I say to contact your carrier before anything else. Most times when this happens, it is the result of a carrier's "processor" not associating one with another, though dates are identical. At the same time, a billing rep in the provider's office will not bill so as to show the connection. And, I've heard that if a 3rd party is not in your carrier's system, they must abide if they agreed to accept assignment, but, check with your carrier first to be positive of their policy in this matter..

dpgirl, thank you for your input on this. You covered it. This causes me to state something else I did not think at the time was important, regarding ER's.

Everyone needs to realize that most ER Rooms are a seperate "business". This is why you receive two seperate billings in most cases. One is for the Doctor, and his group, while the other is for the Hospital. At the same time, as LadynRed pointed out, you should stay on top of the billing process as this is one item that could bite you, if you don't. The ones I was referring to mostly as being the provider's responsibility, has to do with "incomplete info", though inserting your assistance, if you can, is acceptable. Remember, when you sign on the line for treatment, you are relying on the provider to properly complete and submit the claim for payment. This is where you have your argument as you would show how the billing office "erred".

[Methuss]

I don't normally post links for other services, but I think our Admin will allow this one that I just found out about:

http://www.mymedicalcontrol.com/

This company provides healthcare claims adjusting for self insured and uninsured medical bills. They get a percent of what they save for you, but it's like having your own personal claims department pounding down the regular price of medical treatments to what insurance companies pay.

[SBD]

Although this does not necessarily have to do with medical collections, it is very important for those who have underwritten policies to get their report. ASAP

Request Your Record

MIB will provide consumers with record disclosure once annually without charge!

To obtain free disclosure, you must call MIB's toll-free phone number listed below.

A few things to bear in mind before you call -

If you have not applied for individually underwritten life, health, or disability insurance during the preceding seven year period, MIB will not have a record on you.

We will ask you for personal identification information to assist us in locating a record, if one exists. We may validate the identification information that you provided with other consumer reporting agencies.

You will be asked to certify under penalty of perjury that the information you provided about yourself to request MIB disclosure is accurate, complete and you represent that you are the person that is requesting disclosure.

MIB's toll-free number for disclosure is 866-692-6901

(TTY 866-346-3642 for hearing impaired)

Upon receipt of your (a) request for a Record Search and Disclosure, and ( proper identification, MIB will initiate the disclosure process and provide you with:

• the nature and substance of information, if any, that MIB may have in its files pertaining to you;
  
• the name(s) of the MIB member companies, if any, that reported information to MIB; and,
  
• the name(s) of the MIB member companies, if any, that received a copy of your MIB record during the twelve (12) month period preceding your request for disclosure.

MIB is committed to the philosophy that every consumer should be entitled to know the contents of his or her record maintained by MIB and has the right to correct any inaccurate or incomplete information in the record.

MIB is a not-for-profit incorporated trade association operating since 1902. There are over 600 member companies who agree to share information in the form of medical and avocation "codes". There are approximately 230 codes, which MIB uses to signify different medical conditions. A very few of these indicate risks involving hazardous avocations or adverse driving records, etc. These codes DO NOT indicate what action another company took. . .only that further investigation may be warranted.

Also, MIB does not report actual details about the person's medical condition or problem. The codes are simply act as red flags, and alert companies to the fact that there was information obtained and reported by a member company on this particular impairment or avocation risk. For example, if an underwriter, while reviewing medical records discovered that this person had had a heart attack, there would be a specific code to indicate that, and the underwriter would check MIB for such a code and if there was none there, he or she would add this code to the file.

Here's an analogy agents can use to explain MIB to clients. When an inquiry is made by a member company, MIB only tells them that the time on their watch is DIFFERENT from what another member has reported it to be. It will still be up to the individual company to determine for themselves which time is more accurate.

SBD

[lyle7289]

Although this does not necessarily have to do with medical collections, it is very important for those who have underwritten policies to get their report. ASAP

SBD

MIB? (men in Black?)

[SBD]

MIB? (men in Black?)

Pretty much!!

Medical Information Bureau

Works as a central depository for supplying your medical information to

insurance companies.

Once you apply for insurance to one company and they have your records &

they will post this information to the MIB for all other insurance companies to see for all eternity. This way if your rejected from one company you cannot try and fool another insurance company.

SBD

[lyle7289]

got it...Thanks

[someonesomewhere]

Quicken has a product called Medical Expense Manager. Been debating it.

http://quicken.intuit.com/healthcare-management/medical-expense-software.jhtml?lid=site_banner

Juggling provider statements, EOBs, mail order RX, and an FSA can be about as time consuming as fixing one's credit. I look at EVERY provider statement and match to the EOBs. I get paper EOBs in the mail, but I also check online as those are available much sooner.

If anything is ever confusing, I always call the health insurance company. One can try to maintain a good relationship with the CRAs (as Dive has often suggested), but I frequently find myself in an adversarial role with them. Not so with health insurance companies IME, mostly. [CIGNA has reserved seating in Hell.] I call, and they seem more than happy to help. Even had 'em offer to call the provider on my behalf to say, "The patient only owes $X for this bill, per the agreement you signed with our company." Only had to do that once.

With in network providers, I generally don't have a problem. Once or twice had a copayment billed when it should not have been billed. Got credited back to the provider, and the provider didn't refund it. Discovered that while wading thru EOBs and provider statements. To remedy this, whenever someone goes in for a visit, I smile and politely ask at the desk, "Can you check to see whether there's a credit on the account?" Translation, do y'all owe me money that y'all ain't told me 'bout?

Dentists have proven the biggest PITA for excess billing beyond what the insurance company allows. To offset this, I've adopted a tactic which seems to be working thus far. They generally want PIF at the time of services, based upon their "projection" of what the cost will be. I ask whether I can pay half today, and they usually accept. Then I watch the EOB when it hits the insurance company website. Check to see what insurance paid, what I owe, and I billpay the provider right away for the difference between what I already paid and what I owe.

Had one just a few weeks ago. Dentist said I was looking at $336 for getting my teeth drilled. Asked if I do half, and I paid $170 there and then. EOB hit the website, I only owed $220 total. Billpaid the remaining $50. Either insurance paid more or the dentist was guessing high.

Pediatric dentist is even worse. Got overbilled about $340 last year, and it took about 6 weeks to get the refund from the provider. That's 6 weeks AFTER they got paid by insurance, and even longer since I paid 'em. I put up with 'em because they do good work and there's a frustration factor (on my part) of getting a 6 year old to hold still for a regular dentist. My polite but firm tone seems to be helping. Only got overbilled $90 this year. Next time DS sees 'em, they are gonna get the pay half now routine.

[someonesomewhere]

If you have an FSA and regular medical bills, consider it. Kids, chiro, glasses, maintenance meds, and a host of other things add up to predictable medical bills.

Thinking about laser eye surgery? Need to get some teeth drilled and filled? Wanna get that third nipple removed? All things to consider when renewing your benefits in the fall for next year.

Just remember, that the money you put into an FSA is use or lose. If you sign up to have $1,200 withheld, and you only spend $382 in doctor bills for the year, you lose $818. Budget accordingly and make conservative guesses.

On the plus side, if you guess too low, you can usually burn up your FSA account before year's end. Last year, I had $2,400 withheld in an FSA, and I burned it all up by June. $200 a month was being withheld from my check, but I got reimbursed $2,400 by mid year.

Check with your FSA company. Some won't reimburse you the money until the withholding from your check gets to them. That happened with a Dependent Care FSA last year. DS was in preschool for 5 months thru May, we submitted all 5 months of payments, but got reimbursed throughout the year as the biweekly withholding went from my employer, to the FSA, to me in a check mailed.

Still a good deal because the money in an FSA is pre-tax.