Find your diamond
Find your jewelry
shape
carat
color
clarity

Confusing medical billing

CJ2008

Ideal_Rock
Premium
Joined
Dec 31, 2006
Messages
4,750
We have one doctor's office (a dermatologist) who sends the most confusing statements.

I am often able to check the statement versus the EOB and make sure at least the amounts match.

Often we pay balances in more than one time and they don't ever apply payment in a way that I can see that it has been applied - so if I send $50 I don't see $50 credited - they must break it up over the different procedures? But what's even more confusing is that often I'll try to add up the "patient receipts" and they don't add to what I sent in, so it's so difficult to verify that they're crediting the correct amounts.

Especially if in the meantime I've been back and accrued a new charge and a new co-pay, etc.

I discovered that a check I had sent back in December for a little over $40 had not been applied. The girl who handles the billing told me she would apply it but I got the new statement and nowhere do I see the $40 nor are there any amounts that add up to $40.

In the last few months they've changed billing people 3 times. I found this out because every time I wrote in to the email address on the statement I would get a reply "I'm no longer handling billing for them." :???:

Does anybody have any tips for how to read these statements or what to say so that the person handling the billing explains what I need to know?

I just want a clear statement - this is what we did, this is what your insurance paid, this is what you owe, this is what you've paid. :/
 

Queenie60

Ideal_Rock
Premium
Joined
Sep 15, 2014
Messages
4,273
I had a doctor a few years back and the same type of situation was occurring. Just recently found out that she and her partner were being convicted of fraud. They were sending false statements to the insurance companies. Nothing ever matched up and they never had answers for me as to why. I would suggest you keep a detailed log of payments and expenses and take it up with them in writing. Doesn't sound like a good billing situation on their part. Or, call your insurance company, speak to a patient representative and voice your concerns about their billing habits. Since they are probably part of the network your insurance company would most likely be able to assist you in resolving their strange billing habits. Good luck. :wavey:
 

Crazie4Cuts

Shiny_Rock
Premium
Joined
Oct 9, 2014
Messages
430
I would ask for a complete Family Ledger, showing each member and the dates for all services rendered starting from the date you know you had a zero balance (hopefully you will only see info for the past year). The office should have this software so they can easily sort by date, family member, the description of service receive, the amount billed to insurance and what date the insurance has paid. I then having all your EOBs from insurance you can then match what you're co-pay amounts you are responsible for and then also check to see that you did make payment. If a check towards a payment is lost, retrieve it online though your bank to show proof of payment. I would make an appointment with the manager and go to the billing office to be sure your payment was posted and then ask for a print out.

Though this situation is different, I want to tell you about trying to get my money back from an overpayment! I mistakenly payed a medical bill after receiving a statement and it showed my co-payment portion. The company which my spouse works for has a FSA (flexible spending account) and the insurance company pays directly to the medical billing office as the medical office directly bills the insurance for the services I received. So the medical office received 2 payments, essentially I now have a credit on my account. Luckily since I track my payments I should have money coming back to me. Did I automatically receive it? NOT on your life! It took me 3 months (I kid you not) to get my money back! And it was only $35.00. At first I was nice about it and called accounts receivable, so they told me that they would contact accounts payable and inquire for me. I didn't receive a check and called again after 2 weeks. This time I got smart and took the name of the person I talked to and made sure to have this documented. Still no money. I call again after two more weeks and find out that A/R and A/P are NOT EVEN in the same building. Now I'm beginning to get livid and calling during work hours because as you know billing have weird hours and do not answer calls during lunch hours or after 4 pm M-TH ( can't remember if their office is open on Fridays..) So I asked if I could have a name in A/P and give me the name of a manager. It got ugly and I said I am now going to call everyday until I receive my money back, this is outrageous and poor customer service. It goes on because the lady (she was quite experienced and I also let her know I work in the front office in medical too, so I understand these matters) so she personally tried to use her contact in A/P but I still didn't get my money back for like a month or so later. I finally did get a guys name in A/P and he assured me I would get a check, I think I receive it 10 days later. I am sorry that this is lengthy, but do want to let you know sometimes it is best to demand an itemize ledger every time you leave the office and make sure you are not in a rush to leave after your appointment even if the office receptionist says she can mail it to you. ONE should always keep records of every EOB that is sent from your insurance company. Hope this helps...
 

ksinger

Ideal_Rock
Premium
Joined
Jan 30, 2008
Messages
5,078
As someone who has quite a lot of experience in the medical grinder, here is my advice. If you know this stuff already, I’m not trying to imply you don’t. But I don’t assume that people who haven’t been supporting the healthcare industry as a part time job - like me - know the ropes, so here are some of the ropes.

First, KNOW the specifics of your insurance plan. Most important, you need to know your deductible, copays, what % you are required to pay of allowable charges, and your yearly maximum out of pockets - there may be one for medical and a separate one for medications.


It's also helpful to know if co-pays are applied to your total out of pockets. And here I’m going to show that I don’t remember if mine do or not, I THINK they do, but I need to go check again.

Anyway, once you know those things, you need to be ruthless in keeping outlays for those expenses and keeping them recorded by date of service. And I don’t know if this will work for you, but refuse (politely but firmly) when the place - for an MRI for instance - tells you “We estimate that your portion of today’s bill will be $XXX dollars.” Just say, “No, I’ll wait until you’ve filed, insurance has paid, and then you can bill me, that way we’re all on the same page.” They kind of blink at me and go, “OK.”

The reason to refuse to pay estimates is that hospitals are using some sort of service to get the info as to how much you have paid already. My experience has been that it can be an ugly race to see which entity can get their bill serviced first by the insurance company, and the service can’t keep up with the speed of the claims, resulting in erroneous “estimates”. I just got through with a huge fight with a facility that did a few things, and because I kept decent (not great but close enough) records, and because I had a weak moment and committed the ultimate sin of paying that “estimate”, when they tried to hit me up for an additional $3000 dollars plus they were not showing how much I’d already paid for that date, I knew that was utter BS, since I was close to my out of pocket on that date of service. Hell, the charges for the service, minus the amounts they DID say I’d paid, didn’t even add up on their own bill! It was crazy. I feel your pain, trust me. I had to fight with them for almost a year, but not only was that bill utter overblown baloney, they owed ME almost $300. I had to get the insurance company in on it on a 3-way, more than once, but they eventually did pay me back.


Remember, you don’t pay what the doctor bills, you pay whatever % of the amount the doctor and the insurance plan have agreed upon. He bills $500, the agreement is for $150 in ALLOWABLE charges, and you are responsible for whatever % of that, as defined by your plan. Your best ally in all this will likely be the insurance company itself. Do not spend too much time fretting about the bills from the doctor as much as you spend on the insurance statements for that date of service. Unless there is one outstanding like I had above. In that case, I was NOT going to let their stupid system automatically turn me over to a collection agency, so I was all over them. A LOT. They did NOT like hearing from me, I can tell ya.

Bottom line, you’re going to have to spend a bunch of time on the phone, sad to say, with the provider’s billing office, and probably your insurance company. Playing the stupid game is the only way. And you have to be relentless.

After all that I guess I didn’t help you read your provider’s bills, but I’m not sure there IS an good way to do that. They’re all different.

Anyway, best of luck!
 

diamondringlover

Ideal_Rock
Premium
Joined
Dec 12, 2006
Messages
3,795
It is confusing for me and I work for a healthcare company paying medical claims!!!! ksinger gave you very good advice...know what your insurance covers..depending on your insurance plan you should always ask if they participate in your insurance plan, this is called a in-network provider, on most plans if you stay in-network you will pay a lower amount, most participating providers have a negotiated contract with the insurance company and in that contract they agree to write off the balance between what they bill and what the negotiated rate is.....however some participating providers will try to "balance bill" the patient that amount and thet goes against their contract and they are not suppose to do that..that is why it is so important to understand what your plan covers. If you go to a out of network or non participating provider its a free for all..the can bill whatever the heck they want and the insurance may either not cover it all and you will most likely you owe more money. Now if you go to lets say a ER and you can't help who bills what, there can be different types and levels of coverage depending on your plan and what it covers, so know your coverage and if anything seems not quite right...call your insurance company they can explain your benefits to you and they can tell you why something was or was not covered. Always keep track of how much you think you should owe.

My last bit of advice...don't blame the insurance company for what is or is not covered..your employer sets the rules for what is covered and what is not, the insurance company just cover what your employer wants covered and keep in mind we are all human and employee's of the insurance companies do make mistakes..if you feel one has been made call them and please be nice to the person on the phone :wink2:
 

ksinger

Ideal_Rock
Premium
Joined
Jan 30, 2008
Messages
5,078
diamondrnglover|1468106815|4053760 said:
It is confusing for me and I work for a healthcare company paying medical claims!!!! ksinger gave you very good advice...know what your insurance covers..depending on your insurance plan you should always ask if they participate in your insurance plan, this is called a in-network provider, on most plans if you stay in-network you will pay a lower amount, most participating providers have a negotiated contract with the insurance company and in that contract they agree to write off the balance between what they bill and what the negotiated rate is.....however some participating providers will try to "balance bill" the patient that amount and thet goes against their contract and they are not suppose to do that..that is why it is so important to understand what your plan covers. If you go to a out of network or non participating provider its a free for all..the can bill whatever the heck they want and the insurance may either not cover it all and you will most likely you owe more money. Now if you go to lets say a ER and you can't help who bills what, there can be different types and levels of coverage depending on your plan and what it covers, so know your coverage and if anything seems not quite right...call your insurance company they can explain your benefits to you and they can tell you why something was or was not covered. Always keep track of how much you think you should owe.

My last bit of advice...don't blame the insurance company for what is or is not covered..your employer sets the rules for what is covered and what is not, the insurance company just cover what your employer wants covered and keep in mind we are all human and employee's of the insurance companies do make mistakes..if you feel one has been made call them and please be nice to the person on the phone :wink2:
I thought that insurance plans (under the ACA anyway) were required to cover...stuff. Like, the employer doesn't get to say, oh the plan we offer won't cover PT, or blood transfusions, or transplants, etc. Now I know about the Hobby Lobby birth control issue, but that's very narrow, and that doesn't seem to be what you're talking about, is it?

Can you elaborate on what types of things an employer can refuse to cover on the plans they offer?

Oh, and I just ran into a real-life case of something I'd read, that the major insurers, in their never ending quest to charge more and provide less, are closing their formularies. I found out that my insurance company (not plan) no longer covers compounded meds. Pretty sad.
 

diamondringlover

Ideal_Rock
Premium
Joined
Dec 12, 2006
Messages
3,795
it hard to go into specifics..but yes the ACA does require some things to be covered and employers cover it, its a federal law...but a very good example that comes to mind is foot orthotics..some plans cover them and some don't it depends on what the employer wants covered..I don't deal with prescription coverages of any kind or dental only medical so I clueless when it comes to those things. Another example is chiropratic coverage, most plan's cover it, some plans will pay for alot more visits than other's...the major stuff is almost always covered but there can be caps on how much they want the insurance company to pay and how much they want the employee to pay...its all up to the employer not the insurance company on how much out of pocket and employee has to pay. Another biggie is developmental delay in kid's there are various level of coverage and there are some state requirements but there a whole host of hows and whys on what is required to be covered, it gets complicated. It's always good to ask if something is covered if you aren't certain or if you have doubts, you can ask someone in your human resources area they should have someone who can answer the question or they can get a answer or you can call the insurance company and ask and as I said before if the coverage of a claim doesn't seem right to you call the company and ask, they should be able to get you answer.
 

CJ2008

Ideal_Rock
Premium
Joined
Dec 31, 2006
Messages
4,750
Sorry for the delay in responding to you all. I have not looked at any of the bills since I wrote this I think I felt overwhelmed. :(

And thank you so much for all the great advice. :wavey:

I'm going to go through it all and cut out each tip and make a little checklist so I can pick it back up and deal with it.

Queenie I feel like any time a patient can't make heads or tails of what they paid and what was charged it's definitely not a good situation. I will try to see if I can resolve it directly and if not definitely make calling the insurance company for help part of what I do. I just need to go carefully with it only because I happen to really like the Dr. so I don't want to cause her any issues.

Crazie4Cuts getting the ledger from when I know it was zero is a great idea because even if the #s don't make match up as far as exact payments if after all the copays and payments equal, then I know everything's in order. (BTW I had asked for a ledger before, but their ledger reads exactly like their statements - it's not straightforward.) And sorry to hear about your overpayment situation - so annoying and frustrating - but glad you got to the bottom of it and got your $ back!

BTW one time going through old paperwork I discovered a $10 overpayment from like a year ago - I'm happy to say that particular office mailed me a check right away, after they saw my receipt for the overpayment and the EOB showing I should have paid $10 less. (and I totally agree with you, I keep all my EOBs, and lately, I also attach my copay receipt right to it.)

ksinger One of the things this Dr.'s office does is consistently charge a copay as a specialist which is $10 more than a regular visit. And then they credit the $10. But when I tried to get them to just charge a regular copay (put it in the system so I am charged that by default) they printed something from my insurance company that shows she's a specialist. Yet - when I get my EOBs they are sometimes specialist copays and sometimes regular visit copays. I know this is one of the things I need to call my insurance company for but I've been procrastinating on it. It's low priority compared to all the other annoying things I'm dealing with as far as the billing from this Dr.

Yes, yes, and yes to the not paying estimates. I do that already - but - I usually do it because it's sooooo much easier to just wait for the EOB and then compare it to the bill and then pay - plus I don't want to have to chase them for $ if something goes wrong, like it happened to you. But even with my own reasons, hearing you give some more "context" as to what happens behind the scenes helps cement it for me to be firm on that no matter what.

And yeah...I'm sure the Dr.'s billing office (it's one girl) is not going to like working with me on this. She already didn't like getting even 1 call even though I kept her on the phone maybe 5 minutes (and they were clearly in the wrong!)

diamondrnglover it helps to hear it's definitely confusing even for someone who does this all the time. I understand my plan kind of OK but will make it a point to understand it better from now on. But really you know what - I wouldn't even be going this "deep" if I was able to look at their statements and if I sent a check for $52.10 I saw $52.10 reflected. Is that too much to ask? But this is forcing me to look harder and maybe that's a good thing.

Thanks again!
 
Be a part of the community It's free, join today!
    Three-stone engagement ring upgrade
    Three-stone engagement ring upgrade
    Vintage OEC Bracelet
    Vintage OEC Bracelet
    June’s Birthstone Trinity
    June’s Birthstone Trinity

Need Something Special?

Get a quote from multiple trusted and vetted jewelers.

Holloway Cut Advisor



Diamond Eye Candy

Click to view full-size image.
Top