Disclaimer:
If I were you I would read parts 1 , 2 , 3, 4, 5 6, and 7 first. Then again, I am not you. I am also not a lawyer, or a medical professional. I am just an average Jane trying to make it in this crazy world of medical billing. Use my information to get you started and don't use it to replace professional advice.
Do you even have health insurance? Some of you think you do. Sure you have an insurance card with the name of a big health insurance company but you might not have traditional health insurance. Your company may be self insured.
What Does That Mean?
Basically to save on costs your company is assuming the risk and not placing it on an insurance company. They choose to pay a third party administer (TPA) to handle the plan. This third party, which may be a large health insurance company, receives the claims, determines if the care is covered under your "plan", and makes payments to the health care provider. It is their hope claims will not exceed their choice of risk.
Is This A Good Thing?
Like everything in this great country, there are pros and cons:
Pro:
For instance, because it really isn't the TPA that is making decisions, they are merely making sure the coverage is under the plan your employer chose, I have found claims and payments are done in a timely fashion. Likewise if your employer has you pay for some of your medical costs, it will be lower that if they went with a traditional health insurance company. Wellness programs (exercise benefits and regular doctor's visits) are often found more available. They want you to be healthier because it is your health that can drive up costs. The TPA's customer is your employer so it is to their benefit to ensure everything is done efficiently. If you want care that isn't covered you can go directly to your employer and argue your case for them to cover a procedure you need. Unfortunately that goes with a con.
Con:
You employer now has too much personal information about you and your health. Granted there are "laws" that are supposed to protect you from discrimination, however it is my experience employers will always find a legal way to get rid of you if they need to. This is paranoia, but it is also not being naive. This is why you are seeing in the news large employers charging more for their overweight workers or demanding smokers to quit. They are taking on a bigger risk and want to bring down their costs as much as possible.
How Can I Tell If My Company Is Self Insured?
Unfortunately the only way to tell is to ask your human resource department. I didn't know my current employer was self-insured until I was discussing our insurance coverage with a co-worker. After some investigation I found out all of my past employers were self insured. With the cost of health care today, you will probably find your company is self insured.
How Can I Use This To My Advantage?
If you are having a problem with your company's third party administrator, tell them. A phone call of frustration from your employer will get things moving faster for you. Likewise take advantage of the Wellness programs - being healthy is always to your advantage.
Summary
As I have stated, in most cases I found the TPA's with self insured companies are very responsive. Claims are handled in a timely fashion and payment to health care providers are done quickly. One small employer I worked for gave us the business card of their TPA and made it quite clear to contact them immediately if there are issues. This TPA was another small business, and it was great to have them on our side because unfortunately the health care company they worked with was terrible.
Finally, if you are prone to be sick (ie. have a pre-existing condition), this is something that should be disclosed on paper work (if asked), but should not be blasted around the office. Keep close track of the time you take off for doctor visits and make sure that you work additional time to cover this, schedule office visits after hours if possible, or use your allotted sick and vacation time appropriately. You do not want to play into your employer's hand if you get sick and take advantage of their benefits.
Thursday, October 16, 2008
Wednesday, October 15, 2008
Understanding Your Healthcare Part 7
Disclaimer:
I do not work in medical billing, but I do deal with it routinely because in our family one of us has a pre-existing condition. What does that mean? I get to deal with the wonderful world of doctor's offices and hospitals regularly. I have learned some things over the years. I am not a lawyer, but I have been around the block. Use these posts to get you started. You have a choice. You can be lost and not read the past posts, or you can read them 1 , 2 , 3, 4, 5 and 6 first.
I am currently detailing situations where I have had a run in with medical billing. How I dealt with it and the repercussions we faced from it. Here is a fun situation where the insurance company stated they would pay for something but later changed their mind.
Why I Needed Care
While in my dentist's office he took an x-ray. The x-ray found a single impacted wisdom tooth. An impacted tooth is when it is sideways and parallel to the jaw in the gums and perpendicular to the tooth it is next to. This type of setting makes it difficult for removal. I remember distinctly my dentist said, "Frugalicious, you are young without kids. The tooth hasn't done damage yet. The older you get the more difficult it is to find time away to get this procedure done." That spoke to me, do it now why you have the time before it gets worse. Besides, I had some good dental care right?
The Free Consultation
The oral surgeon looked at the x-ray I provided him and said, "Yep, that should come out." He went over the procedure, and wrote me some prescriptions for the big day. I was frustrated because I thought the consultation was just that, initial and not the exam right before the surgery. I talked to his medical billing person who said as a courtesy, they contact the dental insurance company for a quote. The insurance company quoted the medical billing specialist at the oral surgeon's office what my benefits would be for the medical billing codes she provided. Nothing was done in writing, it was all done over the phone. I felt it was affordable and scheduled the surgery that day.
The Denial
My insurance was denied because they gave me anesthesia. For the entire procedure, I was out completely. According to them, it was not a "medical necessity." When I reminded them they talked to the doctor's office and promised to cover the procedure, I was told that "quotes over the phone is not a guarantee of payment." That is insurance speak, for: "We don't want to promise you a thing so we can screw you later." To argue the denial I could get my doctor to explain, "What the underlying circumstance it was to make the anesthesia a medical necessity." The woman at the insurance company repeated this bullsh$t line so much to this day I remember it clearly.
I contacted the doctor's office - frustrated. They said calling the insurance company is a courtesy they provide, and that I am responsible for the bill. Bleh! But, they were willing to write a letter on my behalf to state why the anesthesia was a medical necessity. They would send this letter for me, but I had to write my own for them to include. I decided to contact the insurance company again.
This time, I got a different woman. She told me that anesthesia is covered, but for teeth not tooth. Hmmm...the first women didn't tell me that. Using the advice I received from the State Attorney General's Office consumer protection division, office of managed care - I pulled out my insurance benefits booklet. Sure enough there it was clear as day - anesthesia is covered for impacted wisdom teeth.
The Letter
I wrote a letter to the insurance company to argue the claim denial. I included a copy of my insurance benefits booklet with the statement that anesthesia is covered highlighted. I also stated who I spoke with, the days and times and pointed out that their information was in conflict. My doctor's office letter was attached. I gave this to the doctor's office who mailed their letter with mine to the insurance company. The insurance company found in my favor and paid the oral surgeon.
Summary
Even though your doctor's office helps get a quote for you as a courtesy, do not trust their numbers. Request a copy of the medical billing codes and contact the insurance company yourself. Ask them to fax or e-mail you the quote so you have a copy in writing. I got something in writing from the doctor's office. This is not enough. You need documentation from your insurance company. Typically this is not done for simply appointments like check ups, but rather more detailed medical care like surgery. Even if you don't need prior approval, if you can, you will find it in your favor to weed out issues now before the surgery.
I do not work in medical billing, but I do deal with it routinely because in our family one of us has a pre-existing condition. What does that mean? I get to deal with the wonderful world of doctor's offices and hospitals regularly. I have learned some things over the years. I am not a lawyer, but I have been around the block. Use these posts to get you started. You have a choice. You can be lost and not read the past posts, or you can read them 1 , 2 , 3, 4, 5 and 6 first.
I am currently detailing situations where I have had a run in with medical billing. How I dealt with it and the repercussions we faced from it. Here is a fun situation where the insurance company stated they would pay for something but later changed their mind.
Why I Needed Care
While in my dentist's office he took an x-ray. The x-ray found a single impacted wisdom tooth. An impacted tooth is when it is sideways and parallel to the jaw in the gums and perpendicular to the tooth it is next to. This type of setting makes it difficult for removal. I remember distinctly my dentist said, "Frugalicious, you are young without kids. The tooth hasn't done damage yet. The older you get the more difficult it is to find time away to get this procedure done." That spoke to me, do it now why you have the time before it gets worse. Besides, I had some good dental care right?
The Free Consultation
The oral surgeon looked at the x-ray I provided him and said, "Yep, that should come out." He went over the procedure, and wrote me some prescriptions for the big day. I was frustrated because I thought the consultation was just that, initial and not the exam right before the surgery. I talked to his medical billing person who said as a courtesy, they contact the dental insurance company for a quote. The insurance company quoted the medical billing specialist at the oral surgeon's office what my benefits would be for the medical billing codes she provided. Nothing was done in writing, it was all done over the phone. I felt it was affordable and scheduled the surgery that day.
The Denial
My insurance was denied because they gave me anesthesia. For the entire procedure, I was out completely. According to them, it was not a "medical necessity." When I reminded them they talked to the doctor's office and promised to cover the procedure, I was told that "quotes over the phone is not a guarantee of payment." That is insurance speak, for: "We don't want to promise you a thing so we can screw you later." To argue the denial I could get my doctor to explain, "What the underlying circumstance it was to make the anesthesia a medical necessity." The woman at the insurance company repeated this bullsh$t line so much to this day I remember it clearly.
I contacted the doctor's office - frustrated. They said calling the insurance company is a courtesy they provide, and that I am responsible for the bill. Bleh! But, they were willing to write a letter on my behalf to state why the anesthesia was a medical necessity. They would send this letter for me, but I had to write my own for them to include. I decided to contact the insurance company again.
This time, I got a different woman. She told me that anesthesia is covered, but for teeth not tooth. Hmmm...the first women didn't tell me that. Using the advice I received from the State Attorney General's Office consumer protection division, office of managed care - I pulled out my insurance benefits booklet. Sure enough there it was clear as day - anesthesia is covered for impacted wisdom teeth.
The Letter
I wrote a letter to the insurance company to argue the claim denial. I included a copy of my insurance benefits booklet with the statement that anesthesia is covered highlighted. I also stated who I spoke with, the days and times and pointed out that their information was in conflict. My doctor's office letter was attached. I gave this to the doctor's office who mailed their letter with mine to the insurance company. The insurance company found in my favor and paid the oral surgeon.
Summary
Even though your doctor's office helps get a quote for you as a courtesy, do not trust their numbers. Request a copy of the medical billing codes and contact the insurance company yourself. Ask them to fax or e-mail you the quote so you have a copy in writing. I got something in writing from the doctor's office. This is not enough. You need documentation from your insurance company. Typically this is not done for simply appointments like check ups, but rather more detailed medical care like surgery. Even if you don't need prior approval, if you can, you will find it in your favor to weed out issues now before the surgery.
Tuesday, October 14, 2008
Is It Different This Time?
A friend sent me a link to a video presentation by Weston Wellington, a Vice President with Dimensional Fund Advisors (or DFA). From their website:
Is It Different This Time?
Dimensional Vice President Weston Wellington offers perspective on the unpredictability of market movements, how the current market downturn compares to past bear markets, and the resilience markets have historically shown.
Is It Different This Time?
Monday, October 13, 2008
Understanding Your Healthcare Part 6
Disclaimer:
Unfortunately I am not a lawyer, a health care professional, or a singer/songwriter. To begin, try reading parts 1 , 2 , 3, 4 , and 5 first so you aren't lost, or you can ignore these posts and be lost by starting here.
The first run in I had with balance billing was for some physical therapy my husband (boyfriend at the time) had due to an injury to his hand. It was a strange scenario of events. We just graduated from college, he was still on his parent's health care, but because he graduated it was considered COBRA. He also recently started a job and his health care had not kicked in yet. Who was responsible for the bill?
How it Began
Two years later we received a letter from the physical therapy office with a bill that appeared as though it was created by Microsoft Excel. It was not on an official company letterhead, and had a handwritten note on the bottom: "Mr. Frugalicious, you have an extremely old bill here. Please remit payment."
Gathering Facts
He always paid his copayment, we never received a bill from any of the facilities he used during this time, and we were very confused. I was so angry that two years after the fact they could simply send us a bill and say, "oh yea..pay this." We gathered the physical therapy office hired a new employee who audited their accounts for non payment. This explained why the "bill" was made by Microsoft Excel.
FDCPA
I educated myself about a little act called: The Fair Debt Collections Practices Act and found a great website that helped me understand it better. I learned that they did have a right to collect since at the time it was not passed the statue of limitations in North Carolina. I also learned under the law I had the right to request a copy of all of the documentation they used to determine this "bill." I didn't stop there though.
North Carolina State Attorney General
I also found this great office under the North Carolina State Attorney General's office called consumer protection. Under that office there is a small group called managed care. Guess what their job is? Straight from their website:
She explained it was best to keep quiet from the insurance company at this point and force the doctor's office to get the payment for the old bill. If the insurance company finds the benefit wasn't available to him at that time, they will make us pay them back if they felt there was an error on their end! We decided to do just that.
The Letter
It was after I gathered this information that I sent a letter to the doctor's office stating that under the FDCPA, I had a right to request all of the documentation they used to calculate the "bill". I made it clear I was not requesting medical records (to avoid being charged), but merely requesting the documentation used to determine this "bill". I also pointed out that the "bill", did not appear on official company letterhead. Not that this is against the law, but it was my way of saying, "How can you expect me to take this serious when you threw this thing together?" Just for the heck of it, I stated I wanted all further communication to be through the mail. I have not received a phone call from them yet, so I wanted to make sure I had documentation from them here on out.
What I Got Back
I received a letter from the physical therapy office with photocopies of everything they sent to the insurance company. Since these were not medical records, I was not charged. The letter now appeared on company letterhead and stated that they plan on resubmitting the claim to the insurance company and asked us to wait and "see what happens after that."
A few weeks later I received a phone call from my future mother-in-law stating that the insurance company contacted her. They paid the remaining bill and the matter is closed. To this day 7 years later I have not received a bill from this physical therapy office.
Summary
Do you see how easy this was for the physical therapy office to just send a bill to us and hope for the best? Submitting a claim two years after the fact to the insurance company might be more difficult to receive payment. Scaring a customer into paying is probably easier. Unfortunately for them, I knew our rights and showed them this.
Unfortunately I am not a lawyer, a health care professional, or a singer/songwriter. To begin, try reading parts 1 , 2 , 3, 4 , and 5 first so you aren't lost, or you can ignore these posts and be lost by starting here.
The first run in I had with balance billing was for some physical therapy my husband (boyfriend at the time) had due to an injury to his hand. It was a strange scenario of events. We just graduated from college, he was still on his parent's health care, but because he graduated it was considered COBRA. He also recently started a job and his health care had not kicked in yet. Who was responsible for the bill?
How it Began
Two years later we received a letter from the physical therapy office with a bill that appeared as though it was created by Microsoft Excel. It was not on an official company letterhead, and had a handwritten note on the bottom: "Mr. Frugalicious, you have an extremely old bill here. Please remit payment."
Gathering Facts
He always paid his copayment, we never received a bill from any of the facilities he used during this time, and we were very confused. I was so angry that two years after the fact they could simply send us a bill and say, "oh yea..pay this." We gathered the physical therapy office hired a new employee who audited their accounts for non payment. This explained why the "bill" was made by Microsoft Excel.
FDCPA
I educated myself about a little act called: The Fair Debt Collections Practices Act and found a great website that helped me understand it better. I learned that they did have a right to collect since at the time it was not passed the statue of limitations in North Carolina. I also learned under the law I had the right to request a copy of all of the documentation they used to determine this "bill." I didn't stop there though.
North Carolina State Attorney General
I also found this great office under the North Carolina State Attorney General's office called consumer protection. Under that office there is a small group called managed care. Guess what their job is? Straight from their website:
Created as part of the NC Patient’s Bill of Rights, the Managed Care Patient Assistance Program (or MCPA) provides education, advice, support and information for North Carolina health care consumers with health insurance issues. In addition to providing basic information about how your health insurance works, or helping you interpret your Explanation of Benefits, we can provide direct assistance to consumers who want to appeal the denial of health care services by their health insurance company.They cannot provide legal advice, but they can offer ideas on how to resolve a medical billing situation. The person I was in contact with used to work for an insurance company. She helped me understand that what they were doing was legal. She also told me that by law they did have a right to charge me a small fee for copies of medical records to prove the bill. It was from this office I learned about the importance of keeping your old health insurance booklets. Because the bill was two years old, it was possible the insurance company would get amnesia and conveniently forget these benefits were available to him.
She explained it was best to keep quiet from the insurance company at this point and force the doctor's office to get the payment for the old bill. If the insurance company finds the benefit wasn't available to him at that time, they will make us pay them back if they felt there was an error on their end! We decided to do just that.
The Letter
It was after I gathered this information that I sent a letter to the doctor's office stating that under the FDCPA, I had a right to request all of the documentation they used to calculate the "bill". I made it clear I was not requesting medical records (to avoid being charged), but merely requesting the documentation used to determine this "bill". I also pointed out that the "bill", did not appear on official company letterhead. Not that this is against the law, but it was my way of saying, "How can you expect me to take this serious when you threw this thing together?" Just for the heck of it, I stated I wanted all further communication to be through the mail. I have not received a phone call from them yet, so I wanted to make sure I had documentation from them here on out.
What I Got Back
I received a letter from the physical therapy office with photocopies of everything they sent to the insurance company. Since these were not medical records, I was not charged. The letter now appeared on company letterhead and stated that they plan on resubmitting the claim to the insurance company and asked us to wait and "see what happens after that."
A few weeks later I received a phone call from my future mother-in-law stating that the insurance company contacted her. They paid the remaining bill and the matter is closed. To this day 7 years later I have not received a bill from this physical therapy office.
Summary
Do you see how easy this was for the physical therapy office to just send a bill to us and hope for the best? Submitting a claim two years after the fact to the insurance company might be more difficult to receive payment. Scaring a customer into paying is probably easier. Unfortunately for them, I knew our rights and showed them this.
Tuesday, September 16, 2008
Hurricane Ike - How You Can Help
If you live in the central Texas area:
Capital Area Food Bank
Adult volunteers needed during normal business hours (8am to 5pm)
Food donations today through Friday at their location: 8201 South Congress Avenue (between William Cannon & Slaughter Lane)
Food donations in north Austin tomorrow from 7am-7pm at the I35 and Parmer HEB
Money donations accepted online - specify hurricane Ike relief
Mobile Loaves and Fishes (H.T. UrbanGrounds)
Money donations accepted online
Red Cross of Central Texas
They are looking for at least 200 adult volunteers. To volunteer you must complete an application and background check. For more information go to their website.
Money donations accepted online
Texas Responds
The portal website ran by the Governor's office to funnel money and volunteers to the charitable organizations that respond to disasters in Texas.
Medical Reserve Corps
If you are a medical professional and have time to volunteer you are encouraged to contact the Medical Reserve Corps to coordinate.
Austin Humane Society
They are housing the pets of evacuees
Donate items off of their wish list
Money donations accepted online
United Way
2-1-1 is a free referral hot line for central Texans
They are looking for call center volunteers to coordinate help for Ike victims
If you live outside the central Texas area:
Consider monetary donations. Be sure to specify hurricane Ike relief:
Red Cross of Houston
United Way
Salvation Army
Human Society of Austin
Mobile Loaves and Fishes
Houston Food Bank
If your church or civic group is helping the hurricane Ike victims please leave a comment to direct others on how they can help your organization.
UPDATE: I just got back from Costco to get some stuff for tomorrow. They have boxes there to donate for the hurricane Ike victims. So if you have a membership, and planned to go, you can save gas by having them drop it off for you.
One more thing.....one of the items the Capital Area Food Bank needs are granola bars. Costco's coupons for this month do have kudos bars - $3.50 off. Likewise there are some personal care products with coupons:
Oral-B Advantage Plus Toothbrushes - $2.50 off
Gillette 3x Clear Gel Deodorant - $2.50
Aquafresh Toothpaste - $3.00
Part 6 of my Understanding Your Healthcare Series will be continued tomorrow.
Capital Area Food Bank
Adult volunteers needed during normal business hours (8am to 5pm)
Food donations today through Friday at their location: 8201 South Congress Avenue (between William Cannon & Slaughter Lane)
Food donations in north Austin tomorrow from 7am-7pm at the I35 and Parmer HEB
Money donations accepted online - specify hurricane Ike relief
Mobile Loaves and Fishes (H.T. UrbanGrounds)
Money donations accepted online
Red Cross of Central Texas
They are looking for at least 200 adult volunteers. To volunteer you must complete an application and background check. For more information go to their website.
Money donations accepted online
Texas Responds
The portal website ran by the Governor's office to funnel money and volunteers to the charitable organizations that respond to disasters in Texas.
Medical Reserve Corps
If you are a medical professional and have time to volunteer you are encouraged to contact the Medical Reserve Corps to coordinate.
Austin Humane Society
They are housing the pets of evacuees
Donate items off of their wish list
Money donations accepted online
United Way
2-1-1 is a free referral hot line for central Texans
They are looking for call center volunteers to coordinate help for Ike victims
If you live outside the central Texas area:
Consider monetary donations. Be sure to specify hurricane Ike relief:
Red Cross of Houston
United Way
Salvation Army
Human Society of Austin
Mobile Loaves and Fishes
Houston Food Bank
If your church or civic group is helping the hurricane Ike victims please leave a comment to direct others on how they can help your organization.
UPDATE: I just got back from Costco to get some stuff for tomorrow. They have boxes there to donate for the hurricane Ike victims. So if you have a membership, and planned to go, you can save gas by having them drop it off for you.
One more thing.....one of the items the Capital Area Food Bank needs are granola bars. Costco's coupons for this month do have kudos bars - $3.50 off. Likewise there are some personal care products with coupons:
Oral-B Advantage Plus Toothbrushes - $2.50 off
Gillette 3x Clear Gel Deodorant - $2.50
Aquafresh Toothpaste - $3.00
Part 6 of my Understanding Your Healthcare Series will be continued tomorrow.
Monday, September 15, 2008
Understanding Your Healthcare Part 5
Disclaimer:
I am just a person who is trying to figure out this crazy world of medical billing just like you. Unfortunately I am not a lawyer, or a health care professional. Use this information as a starting point to understand your benefits better. To begin, try reading parts 1 , 2 , 3, and 4 first so you aren't lost, or you can ignore these posts and be lost by starting here.
Friday, I detailed what you can do if you are balance billed. I also explained a situation where my husband and I were balanced billed. Over the next few days I will detail medical billing situations I have experienced while running our families finances.
Second Balance Billing Story
After living in Texas for a year someone attempted to mug my husband one evening. Friends were concerned about him due to his pre-existing condition and on top of calling the police, they also contacted an ambulance. The EMT's came, and gave him a once over. The EMT's were satisfied that he was okay and never took him to the hospital.
A few months later I got a request from the local county EMS requesting our insurance information. I wanted to do what was right, (after all they too have bills to pay) and provided it to them. A few months after this request we received a bill in the mail for $400. According to my explanation of benefits we owed 50 cents, they paid $6.
The fees were plentiful in this bill: a dispatch fee, a non-transport fee (since they did not take him to the hospital), and charges for the few supplies they used. After some investigation I found the county EMS billed the insurance company incorrectly. In other words - the billing codes they used were not correct for the services rendered. The insurance company explained to me that I was being balanced billed. They said the county EMS needed to use the correct codes for billing and would in turn receive the correct amount. I asked if this county EMS were in contract with the insurance company (they were not out-of-network). I was assured they were.
I sent them a letter stating that according to my insurance company (who does have a contract with them) they billed for the services rendered incorrectly. To receive the amount they need, they must work out with the insurance company the correct codes to use for the services rendered. I stated based on my explanation of benefits (enclosed) I only owed 50 cents, as any charges above and beyond was balance billing - which is illegal. I sent a check for 50 cents and stated the matter was closed. My check was cashed for 50 cents, and to this day (3 years later) I have never been contacted by a collector for this, nor has it appeared on my credit report.
Tomorrow I will detail a great story about receiving a bill in the mail 2 years later for a medical bill.
I am just a person who is trying to figure out this crazy world of medical billing just like you. Unfortunately I am not a lawyer, or a health care professional. Use this information as a starting point to understand your benefits better. To begin, try reading parts 1 , 2 , 3, and 4 first so you aren't lost, or you can ignore these posts and be lost by starting here.
Friday, I detailed what you can do if you are balance billed. I also explained a situation where my husband and I were balanced billed. Over the next few days I will detail medical billing situations I have experienced while running our families finances.
Second Balance Billing Story
After living in Texas for a year someone attempted to mug my husband one evening. Friends were concerned about him due to his pre-existing condition and on top of calling the police, they also contacted an ambulance. The EMT's came, and gave him a once over. The EMT's were satisfied that he was okay and never took him to the hospital.
A few months later I got a request from the local county EMS requesting our insurance information. I wanted to do what was right, (after all they too have bills to pay) and provided it to them. A few months after this request we received a bill in the mail for $400. According to my explanation of benefits we owed 50 cents, they paid $6.
The fees were plentiful in this bill: a dispatch fee, a non-transport fee (since they did not take him to the hospital), and charges for the few supplies they used. After some investigation I found the county EMS billed the insurance company incorrectly. In other words - the billing codes they used were not correct for the services rendered. The insurance company explained to me that I was being balanced billed. They said the county EMS needed to use the correct codes for billing and would in turn receive the correct amount. I asked if this county EMS were in contract with the insurance company (they were not out-of-network). I was assured they were.
I sent them a letter stating that according to my insurance company (who does have a contract with them) they billed for the services rendered incorrectly. To receive the amount they need, they must work out with the insurance company the correct codes to use for the services rendered. I stated based on my explanation of benefits (enclosed) I only owed 50 cents, as any charges above and beyond was balance billing - which is illegal. I sent a check for 50 cents and stated the matter was closed. My check was cashed for 50 cents, and to this day (3 years later) I have never been contacted by a collector for this, nor has it appeared on my credit report.
Tomorrow I will detail a great story about receiving a bill in the mail 2 years later for a medical bill.
Friday, September 12, 2008
Understanding Your Healthcare Part 4
Disclaimer:
I am not a health care professional, a lawyer, a person who works in medical billing or a head of broccoli . Use this information as a starting point to understand your benefits better. To begin, try reading parts 1 , 2 and 3 first so you aren't lost.
What Should You Do if You Are Being Balanced Billed?
There are two things I have done to deal with balance billing: One is a do-it-yourself approach, the other is to bring in your insurance company.
Do-it-yourself
Through certified mail with return receipt write a letter to the health care provider indicating that you received certain services (detail) on said date (detail). State that you were billed for X amount, however that is an error. Indicate according to your records you paid your co-payment and your insurance company paid based on the contractual agreement with their facility. Based on your explanation of benefits (a copy enclosed), you only owe: XXX after your co-payment. With the check enclosed for this exact amount, state that you consider this matter closed as any bill above an beyond this amount is called balance billing - which is illegal.
If you do not own anything still include the EOB stating that this matter is closed detailing a bill above the amount you already paid is balance billing. Be firm, but polite. I have found that using the term "balance billing" indicates you are not just some average Joe - you know what they are doing is wrong. Most of the time they will leave you alone after this. Sometimes they will ignore your letter and send you another bill anyways. This is their attempt to intimated you.
Insurance Company
Contact your insurance company and politely explain to the customer service representative that you are confused as to why you are receiving a bill from your doctor's office. Write down the date, the time, the number called, and the customer service rep's name on your explanation of benefits. This is an excellent record for you. Discuss the services you used at your doctor's office with the representative and make sure the services used and the services they were charged for match.
If they do match:
Request that your insurance company contact the doctor's office to request that they stop balance billing you. Typically a letter will be sent to the doctor's office with a copy to you stating their additional charge to you is balance billing. The letter will state that the doctor's office has negotiated rates with the insurance company and that the member (you) are not responsible for any amount above this. Do not be surprised if you still get another bill in the mail.
If they do not match:
Request from the customer service representative what they need from the doctor's office to ensure they are billed correctly. If you are lucky the insurance rep will provide you the codes your doctor's office will need to use. I doubt you will be that lucky. Either way, contact the doctor's office and explain that they incorrectly billed the insurance company for your last appointment and based on your conversation with (rep name) from (insurance company) they need to bill it in such and such a way. I found a phone conversation works just fine for this, however you will still need to write down who you spoke with at the doctor's office, the date, and time.
If you still get a bill, you will be required to now send a letter certify mail with return receipt. This time summarize your conversation with your insurance company, detail they billed incorrectly, and enclose a copy of your explanation of benefits highlighting the services you did not receive. Be firm that the mistake is on their end, and as a courtesy you investigated the matter further.
You Will Still Get A Bill
Just because you know your rights and know that you don't owe the bill doesn't mean that they will stop sending them. After you have documentation that reasonable attempts were made to communicate to the doctor's office that you do not owe the bill including complaining to your insurance company you can try a few more things: Speak to the office in person, complain to the better business bureau, complain to regulatory agencies for their specialty, complain to your attorney general, or simply ignore the letters and monitor your credit report.
Yes, even though you do not owe this money they may pass the information to a collections agency where they will attempt to collect on this bill. They will threaten you with ruining your credit, and unfortunately may place something on your credit report. Do not get bullied by these rouge collectors. Your rights under the "Fair Debt Collect Act" is another blog post itself. Know that you have rights and do not have to pay bills you do not owe.
My Experience
We were routinely balanced billed by a doctor's office my husband went to when we lived in North Carolina. We called the insurance company numerous times, and numerous times they sent a letter to the doctor's office requesting that they stop balance billing us. They continued anyways. My husband found a new doctor because this matter was not being resolved. Talking to them in person did nothing as their billing office was in another city. We ignored the bills, I filed them away along with copies from the insurance company's letters. To this day (some 4 years later) no one has attempted to collect on them, and nothing has appeared on our credit report.
Monday I hope to detail more stories of situations we experienced dealing with medical insurance billing.
I am not a health care professional, a lawyer, a person who works in medical billing or a head of broccoli . Use this information as a starting point to understand your benefits better. To begin, try reading parts 1 , 2 and 3 first so you aren't lost.
What Should You Do if You Are Being Balanced Billed?
There are two things I have done to deal with balance billing: One is a do-it-yourself approach, the other is to bring in your insurance company.
Do-it-yourself
Through certified mail with return receipt write a letter to the health care provider indicating that you received certain services (detail) on said date (detail). State that you were billed for X amount, however that is an error. Indicate according to your records you paid your co-payment and your insurance company paid based on the contractual agreement with their facility. Based on your explanation of benefits (a copy enclosed), you only owe: XXX after your co-payment. With the check enclosed for this exact amount, state that you consider this matter closed as any bill above an beyond this amount is called balance billing - which is illegal.
If you do not own anything still include the EOB stating that this matter is closed detailing a bill above the amount you already paid is balance billing. Be firm, but polite. I have found that using the term "balance billing" indicates you are not just some average Joe - you know what they are doing is wrong. Most of the time they will leave you alone after this. Sometimes they will ignore your letter and send you another bill anyways. This is their attempt to intimated you.
Insurance Company
Contact your insurance company and politely explain to the customer service representative that you are confused as to why you are receiving a bill from your doctor's office. Write down the date, the time, the number called, and the customer service rep's name on your explanation of benefits. This is an excellent record for you. Discuss the services you used at your doctor's office with the representative and make sure the services used and the services they were charged for match.
If they do match:
Request that your insurance company contact the doctor's office to request that they stop balance billing you. Typically a letter will be sent to the doctor's office with a copy to you stating their additional charge to you is balance billing. The letter will state that the doctor's office has negotiated rates with the insurance company and that the member (you) are not responsible for any amount above this. Do not be surprised if you still get another bill in the mail.
If they do not match:
Request from the customer service representative what they need from the doctor's office to ensure they are billed correctly. If you are lucky the insurance rep will provide you the codes your doctor's office will need to use. I doubt you will be that lucky. Either way, contact the doctor's office and explain that they incorrectly billed the insurance company for your last appointment and based on your conversation with (rep name) from (insurance company) they need to bill it in such and such a way. I found a phone conversation works just fine for this, however you will still need to write down who you spoke with at the doctor's office, the date, and time.
If you still get a bill, you will be required to now send a letter certify mail with return receipt. This time summarize your conversation with your insurance company, detail they billed incorrectly, and enclose a copy of your explanation of benefits highlighting the services you did not receive. Be firm that the mistake is on their end, and as a courtesy you investigated the matter further.
You Will Still Get A Bill
Just because you know your rights and know that you don't owe the bill doesn't mean that they will stop sending them. After you have documentation that reasonable attempts were made to communicate to the doctor's office that you do not owe the bill including complaining to your insurance company you can try a few more things: Speak to the office in person, complain to the better business bureau, complain to regulatory agencies for their specialty, complain to your attorney general, or simply ignore the letters and monitor your credit report.
Yes, even though you do not owe this money they may pass the information to a collections agency where they will attempt to collect on this bill. They will threaten you with ruining your credit, and unfortunately may place something on your credit report. Do not get bullied by these rouge collectors. Your rights under the "Fair Debt Collect Act" is another blog post itself. Know that you have rights and do not have to pay bills you do not owe.
My Experience
We were routinely balanced billed by a doctor's office my husband went to when we lived in North Carolina. We called the insurance company numerous times, and numerous times they sent a letter to the doctor's office requesting that they stop balance billing us. They continued anyways. My husband found a new doctor because this matter was not being resolved. Talking to them in person did nothing as their billing office was in another city. We ignored the bills, I filed them away along with copies from the insurance company's letters. To this day (some 4 years later) no one has attempted to collect on them, and nothing has appeared on our credit report.
Monday I hope to detail more stories of situations we experienced dealing with medical insurance billing.
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