Billing 101 for patients

Have you ever gotten a bill from the hospital or doctor and it doesn’t match your EOB from your insurance company?  Don’t always blame your doctor. There are a number of different reasons this can happen.  Bills are often sent to you automatically by a company’s billing software. Sometimes it is a true error. Sometimes it is because your provider is not in network with your insurance carrier.  Let’s do a little background on how the bills come to be from the billing side.

Most billing companies use some sort of billing software.  Once they enter your information and insurance information (demographics) they will enter the charges and bill your insurance (file a claim). Some insurance companies pay very quickly, especially if the claim goes to them electronically.  Other insurance companies are slow at paying or don’t pay at all.  Most billing software has parameters are setup where if a claim isn’t paid within a certain amount of time they will rebelled the insurance or bill the patient directly. Sometimes when this happens the insurance payment may come a day or two after the bill is sent.

The true error.  There are many ways that errors happen in billing.  One of the most common I see is an incorrect or missing network discount.  Every insurance company calls “network discounts” something different but no matter what they are called, it is the discount that a insurance network has negotiated with the provider. The missing discounts are honest mistakes and are usually caused by the confusion from insurance carriers.  For example, Insurance Company A may use Network 1 and Network 2 or even more networks based on the specific policy.  Your provider might have a contract with Network 2 and not Network 1.  Sometimes these are confused by the billing company just like they get confused by you.

Not in network.  If a provider isn’t in network with a insurance company, your insurance usually will apply your bill to your out of network benefits.  Some companies have no problem saying some like you went to an out of network provider and your bill was covered at an out of network rate.  Other companies like to try to hide this.  They will say part of the bill is a provider discount but in the fine print they will admit that your provider can bill you and you are responsible for it.

So what do you do when this happens?  Don’t get mad.  Call your provider and be polite.  The reps will usually look over your account and check for error and verify they did everything correctly. They can give you your correct balance. They can also check and make sure your network discount was applied.  Be patient with them because many of the places this things are checked are slow. They will also inform you if your insurance is out of network. They are usually the best source of information to fight your insurance carrier to get this paid.

What do you do when your provider is out of network?  Things happen. If you  didn’t know a particular provider was not in network when you had your surgery, there are some options.  Contact your insurance carrier to file an appeal.  Some insurance polices have a RAPS provision (Radiologist, Anesthesiologists, Pathologist) which basically says that you used an in network facility and in network surgeon so the RAPS providers will be processed as in network.  Also check to see if there are any in network providers within 25 miles.  Check out FairHealthConsumer.org to see if you are being billed a reasonable amount and if your insurance carrier is approving a reasonable amount.  Call your provider and see if you can get a discount if your appeal is denied and you will pay the balance in 30 days or ask them for suggestions.  When all else fails and you feel that you haven’t been treated fairly, contact your state’s department of insurance and see if they will advocate on your behalf.

A final note.  Your doctor charges a much higher rate than what they are willing to accept as a reasonable reimbursement rate.  Why?  Some insurance providers do not reimburse at a reasonable rate.  Some of the government payers pay some doctors less that what a car mechanic makes per hour.  Remember that doctors are people too.  Many have sacrificed a lot.   Many have huge student debts.  They also have many expenses that you might not consider including malpractice insurance and continuing education.  Many have to take call and miss out on family.  The last thing most doctors want to do is to put a patient in the poor house.

• Ryan Weathers - I have spent over 17 years as a client liaison between billing companies and anesthesiologists. *This note is from my perspective and am not represent my employer or Physcians.  I have done the best to make this more understandable for the average person and to generalize this without pointing out any particular insurance carrier or provider.