The Family Transition Blog

Medical Billing Advocate Explains How to Read Your Bills

If you have medical insurance, you’ve probably received a paper titled “Explanation of Benefits” or EOB.  Typically, just below the title, it reads, “This is not a bill.”  That said, there are dollar figures all over it.  So if this is not a bill, what exactly is it?  The EOB is exactly what it says it is: an explanation of the benefits provided by your insurance plan for a particular service on a particular date.  Its purpose is to report to you (the subscriber) and your doctor or hospital (the provider) exactly how the claim was processed.  It is critical that you review each and every EOB you receive for accuracy and the need to take action.  Not doing so may cause you to become financially responsible for charges that otherwise would have been covered by your plan.  However, most people are intimidated by the EOB and have no idea what to look at or what to do about what they see.  Here then is your guide to your EOB.

While every EOB uses slightly different terms and formats, the key items you need to review are:

• Patient Name: is this you or your dependent? If not, call the insurance company immediately and report the error.
• Date of Service: refers to the date that the visit or procedure or other service happened.  Is it accurate?  If not, report it immediately.
• Provider’s Name: this is the doctor, hospital, or other entity that provided the service.  Often, you will know that Dr. Jones was your surgeon, but the provider on the EOB will be Everytown Surgical Associates.  This is okay, as long as Dr. Jones is indeed part of that group.  If you’re not sure, call the surgeon’s office and ask.  Likewise, sometimes you will receive a bill for a provider you don’t recognize.  If you had surgery, it’s very possible that this is an anesthesiologist, radiologist, emergency room physician, or pathologist who participated in your care and who bills separately.  When in doubt, ask.
• Procedure code or type of service: this is the shorthand where the provider communicates the service for which payment is being requested and is often a five digit number or an abbreviation.  You may see several codes for one date of service as when, for example, you visit the orthopaedic surgeon and have an office visit, x-rays, and a cast applied.  Likewise, when you have surgery there are often multiple procedure codes reported.  One common question occurs when a service is reported as “surgery” but when you don’t believe you had surgery, as when you had a skin lesion removed in the office.  This doesn’t mean that your provider is doing anything wrong or trying to get away with something; rather, it is simply the language of insurer-provider communications.
• Total charge or billed amount: this is your provider’s standard charge for the service.
• Allowed amount: this is the amount your insurance plan will pay under its contract with your provider.
• PPO discount: this is the amount that is “adjusted” off of the bill due to your insurance plan’s contract with the provider.
• Not covered amount: this is the amount your plan does not cover.  Sometimes, this refers to any charge that is above the allowed amount or the “reasonable and customary” charge, and other times this refers to services that are not covered under your plan.
• Copay, coinsurance, deductible: these are the amounts that are the subscriber’s responsibility under the terms of your insurance plan.
• Patient/subscriber responsibility: This is the total dollar amount that you may be billed directly for the date and services reviewed on the EOB and may include amounts that you have already paid at the time of service.  Typically, you will pay this directly to the provider.
• Remarks/remark code/message code: This is the method by which the insurance company communicates with both you and your provider to explain how the claim was processed.  Most often, the codes will be several letters or numbers next to the particular service.  Elsewhere on the EOB you will find the “key” to these codes, which might read something like, “Duplicate charge” or “Not covered on the same date of service as the related charge” or “Not covered due to lack of timely filing”.  There are many, many codes and they vary by insurance company, but this is where you will learn what you or your provider might need to do to have the claim processed and paid correctly.  You MUST review this and take the appropriate action in a timely fashion.
• Payment assigned to provider: This means that whatever payment is being made by the insurance plan is going directly to the provider because he or she is a participating provider in your plan and you signed authorization with the physician to submit the claim on your behalf and receive direct payment.  Where this is not the case, as when you use an out-of-network provider, the check may come directly to you and you are responsible for paying the provider.

If you are confused or overwhelmed by your medical paperwork, a medical billing advocate might be helpful to you.  These professionals are well versed in the ins and outs of medical billing and can help you get problems with your claims resolved quickly and efficiently.

©2010 AttackMedicalBills.com, a division of LifeBridge Solutions, LLC.  All rights reserved.

Fight Medical Bill Errors

Medical bill errors, including those on hospital bills, can quickly become a nightmare for you, the patient, if you don't keep on top of them.  The longer an error goes uncorrected, the less likely it is that you will be able to successfully fix it.  Hospitals, physicians, and other providers are likely to send your account to collections if it is not paid within a few months.  While each entity follows its own guidelines with regard to how quickly it considers an account to be delinquent, most expect your bill to be paid in full unless other arrangements have been agreed to within 90 days of the date of service or 45 days of when your insurance plan has processed the claim.  Failing to pay your medical bills is very likely to affect your credit, and unpaid hospital bills are a major reason why people file personal bankruptcy.

It is particularly critical that you stay on top of billing errors if you have health insurance.  This is because there is something known as "timely filing" in the insurance business.  If you have medical insurance, the plan documents must indicate how long you or your provider has to submit claims.   Once that time has passed, it is permissible for the insurance company to deny your claim because it wasn't submitted within the required time period.  At this point, the entire bill becomes your responsibility.  Similarly, if you don't agree with how your claim has been processed, you have a finite period of time to appeal the decision and escalate it through the insurance plan's dispute resolution process.  If you miss the appeal deadlines, you're usually out of luck.

There are many different kinds of medical bill errors so you must have an eagle eye when you review your bills.  Perhaps the simplest error for a lay person to find is a charge for a service that was never provided.  For example, if you were billed for a hearing test that you never took, make sure to dispute it.  The fact that the clinician ordered the test and marked it on the "superbill" at the time of the visit is irrelevant if the audiologist never performed the test and recorded the results.  Your medical record is the governing document when it comes to these disputes.  If it's not in the records it shouldn't be billed.   If you find yourself in this situation, request a complete copy of your medical records and a detailed itemized statement.  Then, take the time to compare what's in the records with the statement and dispute any discrepancy.

Another common situation is duplicate charges where the provider has billed you for the same service more than once on the same day.  While this makes sense sometimes, such as when you have an x-ray of both your right foot and your left foot, the provider needs to use a special code called a modifier to explain this to the insurance company.  In addition, keep watch for charges for things that the hospital or doctor isn't supposed to bill for separately.  For example, if you have had surgery, the follow up care should be included in the "global fee" for that service.  For major procedures, that means that you shouldn't be charged for a follow up visit within 90 days of the date of the surgery.  You can, however, be charged for additional services other than the office visit itself, such as an x-ray or cast.  Similarly, if you are hospitalized, the hospital shouldn't charge separately for sheets for your bed or your hospital gown, both of which are included in the "room and board" charge.

If all of this seems a bit overwhelming, you might wish to retain a medical bill advocate.  Billing advocates are trained to spot errors, negotiate with providers, and where possible help you to reduce your bills.  You can learn more about medical billing advocacy at http://www.attackmedicalbills.com/ or http://www.billadvocates.com/. 

Does Your Aging Parent Need Help With Medicare?

Have you ever walked into your aging parent's home and seen a stack of Medicare papers on the kitchen table?  Has the thought crossed your mind that maybe you should have these papers come directly to you since they seem so confusing to your Mom?  Is your Dad asking you which Part D drug plan he should select, or whether he should consider a Medicare Advantage program?  Have claims been denied that your parents thought were for covered services?   If so, you're not alone.  Many seniors find dealing with their medical paperwork to be overwhelming.  

Dealing with the sheer volume of medical paperwork can be intimidating for many beneficiaries.  It is important that the explanations of benefits that are received from both Medicare and any supplemental insurance policy be reviewed promptly and if errors are detected, those should be reported immediately.  Similarly, if claims are denied, they must be reviewed and possibly resubmitted if you believe they were denied in error.  Time is of the essence for these matters, since there is a time limit for appealing the carrier's decision.  If you decide that handling these tasks are too much for your parent, you might consider handling it for them or enlisting the help of a medical billing advocate who will review all of the paperwork on a monthly basis, ensuring that your parent is getting the benefits for which she has paid.   In either case, you should be aware that Medicare will only send the paperwork to the beneficiary's address on file with the Social Security Administration or to a properly documented Representative Payee.  (Further information is available at http://www.ssa.gov/.)

What about if your parent simply needs help selecting the right plans?  Each year, Medicare-eligible people are allowed to switch their plan during "open enrollment".  This process begins on November 15th and ends on December 31st.   The best place to start is the Medicare website at http://www.medicare.gov/.   There you can learn about "original Medicare", as well as about "Medicare health plans", "Medigap policies", and "Medicare prescription drug plans."  Which offering is right for your parent will be determined based on a number of factors, including their overall health, finances, and the degree of choice they desire.  You may find that while one approach works well for Mom, Dad is better off on a different plan due to the maintenance medications he takes.  It is perfectly fine for your parents to each select the coverage that works best for him or her as an individual.  Again, if you find that this selection process is overwhelming, a medical billing advocate may be a helpful resource.

War Stories from the Medical Billing Advocate Battlefield

Today was a very interesting session at the Medical Billing Adovcates of America's (www.billingadvocates.com) annual workshop.  We spent the day hearing interesting speakers from the Florida Attorney General's office talk about fraud and abuse as it applies to medical billing.  We also spent time with an attorney who specializes in helping patients fight with their insurance plans and providers.

There seems to be no end to the tactics that providers, especially hospitals, will go to in order to capture extra dollars from payors and patients.  They will try to charge for the drapes and gowns in the operating room, even though they are already being paid for the use of the OR and are supposed to include (or "bundle") those items into the facility fee.  Or, I'm sure you've heard the one about the "infection control device" charge for $17.44 that was actually a box of tissues.  I can tell you that spending the day with more than thirty medical billing advocates reinforces my belief that the profession we are in is absolutely critical to any chance of meaningful health care reform!

I'm especially proud when I hear from colleagues about the many thousands of dollars they have saved patients.  The really nice part, is that so often, in the process of helping their clients, they are also saving "the system" money either directly or by uncovering sytematic fraud that can then be reported to the appropriate authorities.  As we learned today, once a reporr has been filed, the state has the responsibility to investigate and if they find sufficient evidence, they will pursue civil, and sometimes criminal, action against those conducting the fraudulent activity. 

While your medical billing advocate is typically not an attorney and can't provide you with legal advice, we can identify the errors and sometimes outright fraud that is found on an estimated 90% of provider bills.  And once we find these things, we will work on your behalf to get them fixed so that you only pay what you really owe.  From time to time, we will hit a brick wall and advise you to consult with an attorney who specializes in these matters.

More from the battlefield tomorrow.

Tales From the Medical Billing Advocate Battlefield

I have the distinct pleasure of attending the Medical Billing Advocate of America's (www.billadvocates.com) annual workshop this weekend in beautiful Boca Raton, Florida.  Over the next few days I plan to entertain you with war stories I hear from other advocates.  I understand there will be about thirty of us here for the workshop, so I'm certain there will be no shortage of tales from the trenches.

One idea I was kicking around with a few of my fellow advocates tonight was that of creating an "Ask the Advocate" column where people can send in their questions.  If you have an opinion on this idea, we'd appreciate it if you'd share it with us.

In the meantime, stay tuned ... and enjoy.

Why Is Long Term Care Absent From The Healthcare Debate?

As the healthcare debate rages in Washington and around the country, it seems as though a big piece is missing -- long term care.  How can we fully fix the problem of paying for health care if we ignore the reality that even those who have medical insurance coverage often don't have the means to provide long term care for themselves?

Most families don't realize that commercial health insurance and Medicare don't cover much in the way of long term care.  These plans get you through the acute medical situation, such as a surgery or hospitalization, but fall short when what you really need is assistance with bathing, dressing, or moving from place to place.  Health plans will also cover you for the medical care associated with chronic conditions like heart disease or diabetes, but not for the personal care often needed by patients with these disorders.  Long term care insurance policies are available, and for those who can afford them, they are often a very important part of end-of-life planning. 

In fact, the late Ted Kennedy realized that some form of long term care assistance was a key to meaningful health care reform, and is included in the bill that Kennedy's committee wrote as the Community Living Assistance Services and Supports Act (the CLASS Act).  This Act would allow us to buy long term care insurance from the government which would provide a cash benefit when care was indicated.  While this Act wouldn't solve the whole long term care issue, it would be a start and at least provide affordable baseline coverage for all Americans who want it. 

While I have your attention, have YOU and YOUR FAMILY thought about how you will manage the caregiving puzzle?

Medical Claims Made Complicated By Secret Prices

There was a terrific article over the weekend by Carla K. Johnson of the Associated Press regarding the lack of price transparency in health care.  As Ms. Johnson writes, "Finding out how much a medical procedure costs is more difficult and mysterious than buying a new car.  With a new car, there's a sticker price.  With health care, there's no starting line for haggling.  The deal making happens behind closed doors long before patients get involved ... For the uninsured, the hopsitals and doctors charge more -- sometimes much more -- than what they charge insurance companies."  (check out the article at www.associatedpress.com and search for "Health-care marketplace thrives on secret prices")

As a medical billing advocate, I can tell you first hand that the lack of even a "suggested retail price" for medical services makes it so difficult for even informed consumers to make rational decisions when purchasing care.  Consider this case study: 

You find out you need surgery.  Your doctor recommends three surgeons.  Two of these surgeons participate in your preferred provider plan.  Your doctor's first choice does not.  Since you trust your doctor, you call her preferred surgeon first.  You speak with the office manager, who tells you that the surgeon's fee for your type of case is about $50,000 and does not include the hospital or the anesthesiologist, etc., but she quickly adds that she will "work with your insurance company to get your case processed out-of-network."  After you take a deep breath to recover from the sticker shock, you ask her to get clearance from your insurance plan before you schedule a pre-op consultation. 

About a week later, having heard nothing from the surgeon's office, you call back to speak with the office manager once again.  She tells you that she has submitted the "codes" to your insurance company and they have agreed to cover the surgeon out-of-network.  She then tells you that you will need to pay a deposit prior to surgery "just in case", but that the insurance companies "always" pay her doctor in these situations.  You decide to proceed, pay a $7500 deposit, and have your surgery.

About a month after your surgery, you receive paperwork from your insurance company, indicating that the "allowed amount" based on "usual and customary" for your surgeon was just under $5,000 and that your "patient responsibility" is the balance of the charge, since the provider was out-of-network.  Imagine your shock when you realize that you STILL OWE nearly $40,000!  How can this be? The surgeon's office told you that your insurance plan had agreed to cover your case.  What gives?

The first issue is that "usual and customary" (UCR) is a closely guarded secret. Even if you had called your insurance company upfront with the specific procedure codes, they might not have told you those amounts.  If they had, you would have found out that UCR in your surgeon's zip code was about $8,500 nowhere near the $50,000 your surgeon charges.  Had you know that, you would have known that your plan would only pay 60% of UCR since that is all your out-of-network benefits cover.  You could then have made an informed decision about whether you were going to use that particular surgeon.

So what is an informed medical consumer (otherwise known as a patient) to do? Ask questions up front.  Lots of them!  And if you need help, consider engaging an medical billing advocate before you make any of these decisions.

Seven Tips For Dealing With Health Insurance Claims

Dealing with medical bills and insurance claims can often become a full-time job.  The first step to making sure this doesn't happen to you is to become familiar with all of the details of your coverage.  For example, if your insurance has both in-network and out-of-network benefits, you need to understand the difference.  When you make an appointment with a new provider, be sure to ask if they are in your network and then check this out yourself on your insurance plan's website or by calling their customer service number.  Likewise, many plans require a referral and/or pre-certification for certain visits to specialists or for specific procedures.  Don't assume that your doctor's office has checked this out for you.  If they say that they will take care of it for you, call your insurance plan yourself anyway and find out if the provider did indeed c all and whether the service will be covered and at what level.  Understand the difference between what your provider charges and UCR (usual, customary, and reasonable).  Most plans pay benefits based on a percentage of the lower of the charge or UCR and not based on a percentage of the actual charge.   Finally, understand your deductibles and co-insurance responsibility.

Even when you do everything suggested above, there will be times when you don't agree with a provider's bill or how your insurance plan has processed the claim.  In that event:

1. Keep detailed written records of every contact you have with the provider or insurance company - dates, times, who you spoke with, what they said, next steps, etc. If you fax something, keep a copy. If you email something, keep a copy. If you mail something, you guessed it, keep a copy.

2. If the customer service person makes you a promise, get it in writing. So if the hospital says they will adjust or write-off a charge, ask for written confirmation, preferably by email. If the claims adjuster says that they will investigate your issue, ask for them to write you a note indicating this, along with a projected timeframe for their response.

3. If your account has wrongly been sent to collections, demand that the provider immediately correct this and provide you with a written explanation that you can send to the credit reporting agencies.

4. Request detailed bills from your provider, and review them carefully. If you don't understand a charge, ask for an explanation. If the explanation doesn't make sense to you, ask to speak to a supervisor. If you believe that a charge is inappropriate (either an error or outright fraud) don't hesitate to challenge it, preferably in writing. If you believe fraud is involved, report it to your state's insurance department and/or federal agencies (in the case of Medicare, for example).

5. If something doesn't make sense to you on a bill or explanation of benefits, question it right away. There are usually grievance or appeal procedures, but these must be done within the timeframes stated in your policy documents.

6. If you are told not to pay a bill while it is being researched or revised, get it in writing! If you agree to a payment plan or a partial payment as "payment in full", get it in writing!

7. Oh, did I mention, get it in writing!

If you don't have the time to handle your medical bills and related insurance yourself, there are professionals available to assist you.  Insurance claims advocates are there to take care of these issues for you.  You can choose to have an insurance claims advocate review all of your medical bills, or only engage one to assist with sorting out a difficult issue.