Saturday, December 22, 2012

Billing Addresses Mean Everything

When it comes to processing claims, many patients don't know that the provider billing information means everything when it comes to paying the claim correctly. This little section of information can mean the difference between processing your claim in network or out of network.

First, let me give you a quick background on the evolution of provider billing information. Years ago, providers were issued a number as an individual provider called a UPIN. Additionally, they would have a group number to identify them with each practice, and then they would have an individual and group number with each separate insurance. Of course, each group practice had a Tax Identification Number.

Then the government said all of this needed to be simplified and the answer was the NPI or National Provider Identifier. This was to replace all other numbers for a provider, except of course the Tax Id.

You would think with this concept that insurance companies could process a claim and find a provider with just the NPI, right? Nothing could be further from the truth! Instead of relying on just the NPI to process a claim, insurance companies have added additional edits in their system to make sure they're paying the right provider.

For instance, when a claim arrives in the insurance company's system the NPI may be matched first but then the next edit will be to look at other pieces of information such as the way the provider's practice or street address is spelled. If these aren't exact matches, the claim is kicked out for manual processing.

The next step is for an individual to review the claim and match it in their system. This will depend on how the provider's information is listed in what their looking at. In most cases, the provider's information is listed in a pull down menu format so that the processor has to scroll through the list. If they're in a hurry, they're not going to scroll long!

If you have issues with your claims processing out of network in error and you're sure that your provider is in network, it's a good idea to ask about the provider billing section of the claim. Ask the provider exactly what was sent in that field on the claim. Then ask the insurance company exactly what they received in the same field. These two simple questions may help you get your claims issue resolved much quicker.

Tuesday, November 27, 2012

Know Your Healthcare Plan

When people go to buy a car, they know exactly what they're paying for. They know the year, the model, how big the engine is, and most certainly how many miles they have to go before the warranty runs out.

It's not the same when people purchase a healthcare policy. Yes, they may know their deductible and co-pay, whether or not they have out of network benefits. But rarely do they know things like whether or not a DME or Orthotic falls under their usual deductible or if it falls under a completely separate deductible. By the way, most of the time DME products do fall under a separate deductible.

When it comes to health insurance even the most highly educated are at a loss of what their healthcare pays and doesn't pay. That's understandable since those that work with healthcare claims every day struggle to keep up.

Become educated about what you're paying premiums for every month. You probably know what you're spending your money on in every other aspect of your life -- your healthcare shouldn't be any different just because it's complicated.

If you don't know what your policy covers, how in the world do you know whether or not you're being billed for something you shouldn't be? You don't! If you don't know what your policy should cover and at what percentage, how can you argue when you're billed the wrong amount? You can't!

Your best weapon in getting your claims paid is to know your policy inside and out. In the long run, knowing what you're paying for every month will help you avoid paying for something you shouldn't be paying for.

Tuesday, October 30, 2012


The average amount of time that it takes for a health insurance company to re-process a claim is around 90-120 days. That's a conservative estimate if the reason that the claim is being reprocessed is complex. For more substantial issues you're looking at a minimum of 120 to 180 days. It's not uncommon for insurance companies to take as long as three years to resolve claims errors.

I could go into all the reasons that it takes that long to re-process a claim but I think I'll save that for a later date. At this stage in the game, you're probably more interested in just how to get the dang claim paid!

The first rule of getting a claim reprocessed faster is to be THE squeaky wheel. By that I mean be THE absolute number one person that they want to get rid of before everyone else! You have to get so familiar with the customer service department that they recognize your number on caller ID. Be the patient that calls every day, or at the very least every week, just to see how your claims issue is coming along. Pretty soon they'll tire of your voice and they'll push your claim through just to get rid of you because they know if they don't, you're going to call just like clockwork.

The second rule of pushing your claims issues to the forefront is to provide and obtain all the details you possibly can. You can never have too many details when it comes to getting a claim re-processed. Getting a person's name is somewhat elementary and goes without saying but it's amazing how many people don't write down the name of the person they spoke with.

It pays to go a bit further, however. Get a direct extension and the exact department from the person that is helping you with your claim. Get the name of their supervisor. Specifically request a reference number and whether or not a new claim number will be issued.

The last rule after you have all the details is to ask when you can expect the claim to be reprocessed and when they will call you back. By asking those two questions, you'll be setting an expectation up front that you're expecting accountability.

If you implement these three little rules when you call to get your claim re-processed, you can bet you'll see a quicker turnaround time in reprocessing your claims. Most likely the initial time you invest for the first claims issue will pay off for any future issues as well.

Monday, April 23, 2012

Just Because You've Paid Doesn't Mean It's Over!

Most people believe that when they've paid their portion of a medical bill it's over and done with. Nothing could be further from the truth!

Insurance companies do internal audits all the time to check for claims that they shouldn't have paid, or to check for claims they over paid. In some cases such as eligibility, there's no time limit as to how far back they will check claims. In other cases the time limit will be dictated by state laws.

Providers may also have internal audits in place to check for claims that were underpaid or denied line items. Speaking from personal experience, it's not at all uncommon for providers to notify the insurance company of such underpayments and then have to haggle their case for two or three years. Providers will also audit for posting mistakes as well which can cause you to be re-billed for the correct amount when the mistakes are corrected in their system.

What happens in these cases is that when the insurance company re-reviews a claim, they also review your co-insurance and deductibles for the CURRENT time period. So while you may have met your deductible in 2010 it's now 2012 and you have not and you could owe additional money. In this scenario you could be getting a bill for something you thought you paid two years ago!

So what does a patient do in these scenarios to avoid being paying for something that they shouldn't?

First, keep a copy of your EOB's for at least two years and longer if possible so that you have record of the original record of how they processed the claim. Most insurance companies will purge their records online after 18 months. In these cases it's impossible to get a duplicate copy of an EOB unless you jump through a lot of hoops. If you do need an original copy of an EOB that they say they've purged, ask them if they would have it if you were an IRS agent doing an audit -- in that case they would have it!

Second, it's a good idea to keep proof of your payments on your medical bills AND your insurance premiums for at least five years. You need to have a way to prove that you paid your bill or that you had coverage should any errors occur -- and they often do!

Third, get familiar with your state's laws regarding time limits to file claims and bill patients. Most states have laws in place because of scenarios such as this. If you know the laws you'll know whether or not you're being billed for something you shouldn't be. 

Fourth, verify with your provider why you're being billed at such a late date for something you've already paid for. Are they billing you because they billed you incorrectly the first time or are they re-billing you because the insurance company re-processed your claim?

Last, verify with your insurance company if they reprocessed the claim and if so why? If they're processing an old claim against current benefit levels, ask them why you're being penalized for THEIR mistake? Don't be afraid to argue with them over this point.

Monday, April 16, 2012

Patients Pay Things They Shouldn't!

I'm amazed at how often patients will pay a bill they shouldn't pay from their medical provider just because they were billed. It happens more often than you think and by people that come from all walks of life, including the highly educated.

So how does this happen? While the process is somewhat easy to define, the attitudes that allow it to happen are not.

I'd like to talk about process first as the big assumption is that doctor's bill their patients erroneously in error to make money. That's just not the case the large majority of the time.

When an insurance company pays a claim, they will send a detail of the payment called an EOB or EOP -- Explanation Of Benefits or Explanation of Payment. Most of the times, there will be several hundred claims included in one EOB. The lists of charges, write offs, payments, and patient responsibility will be in column format. Each insurance company uses their own format and wording so it's difficult to get in a routine for posting payments when they're all different.

Sometimes what happens is that a poster will post the write off as the patient responsibility leaving a balance that is higher than what the true patient responsibility is. Other times it may be a simple transposition of numbers. Either of these can result in an incorrect balance that's billed to the patient in error.

When you're trying to work though hundreds of claims in a day and trying to follow the different formats, keying errors such as these are likely to happen. It's just a fact of a asystem that is set up to handle a massive amounts of information that flows back and forth.

Some offices may have software in place to catch errors such as this, however when the main focus is bringing money in and keeping your head above water, posting errors often fall to the wayside and are put on the back burner. They're just not a high prority when insurance companies have deadlines.

Most of the time, patients will pay without questioning because they just don't want the hassle of having to pull out their insurance paperwork and compare it to the statement. Besides, it's confusing!They figure that the provider's office is on top of what they should be billed. This is just simply not true and the result is that patients often pay for things they shouldn't.

So how do you avoid paying for something that you should be? First of all, no one has more time to look after your pocketbook than you do. Yes, it requires some effort on your behalf but it's your money so invest the time.

Be sure to keep your Insurance EOB's so that you can compare your medical provider's bill to what your EOB is stating you owe. Verify that the charges and the write offs are the same as well as the amount that the insurance company states you owe. The statement from your doctor should mirror your EOB.

If you see any discrepancies, call the doctor's billing office and ask them to review your account. Have your EOB and bill in hand along with a calculator. The call will go much smoother if you have the information to help the billing staff find your account easily. When explaining your reason for calling, be brief but specific about the issue and how you think the error occurred.

Friday, April 6, 2012

Benefits Exhausted - What to do?!

Once again this week offered up an opportunity for insight on healthcare insurance issues.

Someone I know needed some continueing ongoing medical services that was going to be over $70,000.Their particular insurance plan had a limited number of visits for this particular type of service and they were well past. In other words, their benefits were exhausted for that service and the insurance just wasn't going to cover it.

Of course, then the question becomes how important is your health? Do you forego treatment because that's a heck of a lot of money? It's a hard call even if you can pay for it over time, granted you'll be paying until you're 100!

So what do you do in a situation like that? The first thing is DON'T give up because it seems to hard. Second is seek all the knowledge that you can!

If your insurance isn't going to pay because you've used up your benefits, start looking for resources. Talk to your state's medical association for providers. They may know of state or federal programs that are not well known to the general public. They may also know of state guidelines and laws that may help you out.

Also contact your insurance and verify what your benefits are. Also ask them for ideas on what you can do to receive treatment. The medical and insurance communities are full of information and resources that patients don't always know about. But you have to dig and ask questions to find out.

Ask the provider if they have a sliding fee program that gives you a discount based on your income. Some organizations are required to have such a program if they receive government funding.

You'll never receive if you don't ask! See if the provider will cut you a deal. A lot of providers will offer self pay or prompt pay discounts but you have to ask in most cases.

Make payment arrangements. If you make payment arrangements, be sure to take all your medical bills into account. Some trauma patients will make payment arrangements with the first provider that calls them after their ordeal. They'll promise to pay $100 a month only to be contacted by providers that they didn't even know treated them in the hospital. It's easy to have ten $100 dollar a month payment arrangements in that case! That's $1,000 a month!

Another option available nowadays is a healthcare credit card. Care Credit is one the first that comes to my mind. I will say if you go this route, be absolutely sure to make your payments each month. They're a little trigger happy on the collections if you miss from what I hear in the medical community. But if you're out of options, this might be an alternative.

The bottom line is, only you know what your health is worth to you. So don't get discouraged and dont give up. Keep searching for alternatives until you find a way to get the healthcare you need!

Saturday, March 31, 2012

Why Patients Need A Guidebook!

I've written a guidebook for patients on how to get their health care claims paid that as of yet is unpublished due to lack of interest by agents and publishers. Yet it never fails on a weekly basis I'm constantly pulled into conversations about claims that aren't getting paid or patients that are not being billed correctly, not to mention it's one of the hottest topics on the horizon with all the changes coming up. It's obvious there's a need for a guidebook or at least some helpful information for patients so that's why I started this blog. To share the experience and knowledge I've learned over the years and am continuing to learn on a daily basis!

When you mention health insurance to most people, their eyes glaze over. It's just too complicated. Well, guess what? It's complicated for those like myself that deal with it on a daily basis! Not only do we have to keep up with all the insurance company's legal jargon that changes practically every day, but we also have to be part lawyer, part doctor, and part IT Specialist just to navigate the medical billing process.

If those of us in the industry have to be all of these things, then how does a patient that's on the outside without any inside knowledge know how to navigate the medical billing world when there's a problem? They don't. They have to learn through trial and error regardless how they feel, or they just pay the darn bill they don't owe because they're tired of making phone calls and trying to figure it out.

So in the months to come, my plan is to keep writing and sharing my experience to maybe help someone else. There will probably be a little venting thrown in there too from time to time! Stay tuned -- we all may learn something!