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!