Investigate The Hype

The healthcare industry has received quite a bit of unwarranted flack due to recent articles published in the +New York Times and +Time Magazine   basically stating that the reason that healthcare costs are so high is because hospitals are over charging and someone needs to do something about it. Having worked in the medical billing industry for over a decade, and having a written a book for patients based on that experience, I will be the first to say it's obvious that these articles were written by people with very limited sight that don't have a clue how the healthcare business operates. Heck, half the people that work in it don't have a full grasp which is why I wrote my book in the first place! 

The problem with these types of high profile articles that get everyone on the 'legislate the hospitals' bandwagon is that they fill patient's heads with wrong information and cause them to focus somewhere other than the true issues at stake. These articles should be informing the patient about how the healthcare system operates so that they can figure out why they were billed the wrong rate in the first place. In regards to politics should look at why healthcare expenditures are higher than they ever have been.

While I could spend hours arguing the true reasons for high healthcare costs, suffice it to say that instead of holding up a hospital bill and yelling that it's high, maybe someone needs to dig a little further and ask the right questions that obviously these journalists know nothing about.

So what are some of the questions that should have been asked and should be asked by patients themselves?

Does the hospital or provider have a contract with the patient's healthcare insurance? If so, that in itself limits what the provider can bill a patient. Providers sign contracts agreeing that they can collect a certain rate per service. This is called the "Allowed" rate. A provider can charge what they want to but they can only COLLECT from the insurance and the patient what they have agreed upon in the contract.

Most personnel in medical billing do not have a good grasp of what an "Allowed Amount" is. That lack of understanding is one of the top contributors to patients being billed wrong amounts.

Another question to ask is if all the amounts add up? An "Allowed Amount" should always equal charges minus discounts or adjustments, -or- insurance payments and patient responsibility.

It's not at all uncommon for an insurance explanation of benefits (EOB) to not add up. In my experience, this has been due to a software glitch in the insurance company's software system. Another cause is that the insurance company has the provider loaded incorrectly in their provider records.

One simple question to ask is if the insurance EOB matches the provider's bill. Most insurance payment remits are sent electronically. Formatting issues between the insurance company's system and the provider's software can often cause incorrect discounts or patient's balances. Most of the time this type issue is never caught unless the patient calls with a question about their bill.

Another question to ask is if the services were actually done. Due to the high volume of data entry and the pressure of deadlines imposed for charges to be entered, it's not uncommon for typos to occur on a frequent basis. Everything in healthcare is done by numbers. It's easy for numbers to be transposed and when that happens, wrong codes are billed or charges are put on the wrong patient's accounts. When software incorporates logic that links family accounts or links guarantors with patients and the chances double.

Software system glitches, typos and human errors are the main contributor to erroneous healthcare bills that are higher than they should be. These issues can cause a patient to be billed $500.00 when they should have been billed $200.00. The truth of the matter is that these errors often are undiscovered due to the sheer volume of data entry that is involved and the lack of personnel to do audits. An even larger truth is patients pay them without question the majority of the time.

Instead of buying into the hype that providers are evil and are just over charging to make a high salary, dig a little deeper and verify what you're being billed first. Remember that errors occur, people may not understand how your insurance works, and sometimes a lot of questions need to be asked to find out what is correct.

The numbers matter!

We all know Obamacare is bringing some new changes in healthcare. This past year, the AMA gave an Obamacare presentation at a healthcare software conference that I attend every fall. Interestingly enough, the main takeaway from that presentation is that even they can't decipher and keep up with all the legal jargon that's included in Obama's ever changing healthcare plan.

This past week however, I managed to experience parts of the new healthcare plan first hand through changes in my own healthcare coverage which is employer based. I have to say these new changes are definitely going to put a kink in getting any healthcare claims paid correctly. Quite honestly, from a practical standpoint, I don't see how either side is ever going to manage just the portion that I experienced.

For the last several years, my employer has offered a Wellness Screening or health assessment at no cost. With the blood pressure check and labs it's like an annual visit at your primary care doctor. What's not to like, right?

A couple of years ago, they upped the ante a bit to offer an incentive to participate in the Wellness Screening. If you decided not to participate, your premiums would cost more each month.

This year they upped the stakes a lot more citing that it was a government mandated program. While our premiums have not changed, our deductible has doubled with one caveat that is dependent on the results of the Wellness Screening.

The initial Wellness Screening will take place this month to get a baseline of levels including BMI, Cholesterol, Triglycerides, and Fasting Glucose or Sugar. Additionally, any counseling based on those levels will be prescribed. In August, right before corporate year end, a second Wellness Screening will be done to evaluate any progress or regression.

Based on the progress from the August labs and adherence to counseling, employees will have an opportunity to deduct $100 off of their annual deductible. For instance, if you lower your BMI levels by 5%, you can reduce your deductible by $100 the following year. If your BMI does not decrease even though you attend regular counseling sessions, your deductible will increase from the previous year.

The initial premise of this kind of plan is that it divides healthcare costs fairly. In other words, why should a willfully healthy person foot the bill of a willfully unhealthy person. I must say it makes initial sense, however I personally can see where this can easily go awry with mismanagement over time to include discrimination against health conditions such as diabetes, asthma, and even cancer in certain situations.

The kernel of truth to take away from my own experience is that sooner or later knowing your numbers will matter in getting your claims paid. Not only will you need to know what is covered under your plan, but you'll need to know what your own cholesterol levels are so that you can argue when your deductible has been applied incorrectly! It's been hard enough for insurance companies to keep up with a straight deductible and it will be impossible for them to manage your policy based on your lab results.

No one can keep up with your lab results better than you. In the end, not keeping up with those numbers can cost you $100!

Give It Time!

So often I talk to people that have worked themselves up in a tizzy because they received one response from their insurance and another from their provider's office on a claims issue. While it is entirely possible to call back three times and get three different answers, often times the discrepancy in answers can be attributed to time lapses.

The typical time period for a provider to enter smaller charges into their system is two days. Surgeries and more complicated bills can take up to a month. Once charges are entered into the system, it takes an average of two to three days before the claim actually arrives at the insurance company's electronic claims system.

The usual time that it takes an insurance company to process a clean claims is 14-30 days.It takes 60-90 days at best for a claim to be reprocessed by the insurance company.

Most of the time patients will receive their explanation of benefits before the provider's office receives their copy along with any payment. This is true for the initial processing as well as claims that are reprocessed.

Depending on staffing and set up, it can take anywhere from a week to a month for a provider's office to post a payment or to post an insurance response to an account. The time period for a claim's issue to actually be reviewed and worked can range anywhere from a month to three months.

Because of these lapses in time, it's not uncommon for statements and insurance responses to cross in the mail. When this happens, a patient may get a statement for a claim that's already been reprocessed.

In order to be efficient at getting your claims issues resolved, and to keep your blood pressure in check, it pays to understand the common time lines that providers and insurance companies work on. This will help you determine if what you've received or have been told is up to date and the final answer.

Follow Directions!

Following directions can mean the difference between getting your healthcare claim paid or denied. Every insurance company has a specific appeal payment policy that includes how to file an appeal if you're a provider or a patient. The key is to know what that policy is and follow it exactly.

Most insurance companies have their appeal policies online. Sometimes their requirements, including the appeal form, is somewhat hard to find. In many cases, they'll address appeals under their payment policies or under patient rights.

If you have trouble finding the information you need, use the search function on their website with the term, "appeal form". Most of the time that can help you quickly sift through all the information and get to what you need. If that doesn't work, call their customer service department and ask them where to find it. You don't want to just ask what their appeal policy is - you want them to help you find it on their website. The reason for this is if they give you erroneous information, you won't have anything to fall back on.

Something as simple as leaving a box unchecked, using the wrong form, or not attaching information can  cause an appeal to automatically kick out. Make sure you use the correct form and that it's completed correctly and that you have attached relevant information.

Information such as EOB's or explanation of benefits, are critical in getting your appeal processed. While it is true that they have the EOB on file and you've provided the information on the form for them find it, all insurance companies will still require this one piece of vital information.

Any other information that backs up your appeal is critical as well. Copies of your policy and/or copies of your medical records will go a long ways in proving your point.

It goes without saying that you want to keep copies of everything you submit in your appeal. This way if you have to re-submit due to a denial you only have to make copies instead of recreating the whole appeal.

While gathering all of this information seems like a lot of work, especially when the insurance company has all the information on file, it's well worth the effort in the long run. You don't want to give them any more reason to reject your appeal so do the homework and follow their instructions by submitting a complete appeal.

It's All In The Detail

Any time you're billed for something that you believe you shouldn't be, details are of the utmost importance. They can mean the difference between paying and not paying. 

When you call, get the name and number of the person you spoke with. Ask if they issue reference numbers and write that down. If you're asking if something was paid by the insurance, get check amounts and numbers. If they state they received a claim, ask what was on it and write that down as well. You can never collect too many details. You never know when they may come in handy.

The same principal applies if you're appealing or disputing a claim. The first detail is whether or not your insurance company will consider your "dispute" an actual appeal, reconsideration request or an inquiry. While this may be seen as a mundane splitting of terms, it's actually critical information. Some insurance companies will only let you appeal two or three times but yet they'll let you send in an inquiry or reconsideration multiple times. We all know insurance companies rarely get it right the first time and multiple disputes have to be sent in in most cases.

Some things can be resolved by phone calls. However other times it's best to send in a dispute in writing. When you're sending in a written dispute you want to be concise and to the point. If a processor sees a long winded appeal with too many details, they'll most likely process it as a duplicate because they don't want to take the time to read it! They're cramped on time, remember?

While you need to get to the point in writing your appeal, you still need to include enough details to make it easy to understand. I always say you need to draw them a picture and assume they can't add. While that may seem comical, it's effective and you can include just enough details to get your point across.

Tools like bullet lists are handy to show the history of your claims history. You can detail out what has happened on the claim without having to say over and over again, "Then I called.... ". It's all there in order.

Another detail tool is an equation. If you're only supposed to pay 20% and you're being billed for 30% do the math for them right there on your written dispute. When things are calculated out in an appeal, the success rate goes a little higher just because the processor is not having to do the math and double check your request.

As they say, the devil is in the details. Gather as many details as you can and respond with only what you need!

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.

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.