Denied Insurance Claim

I received an EOB (explanation-of-benefits) in the mail today for my husband.  We had just changed our insurance on the first of the year from a HMO to a PPO.  We decided we needed a little more flexibility with our choices.  The HMO would have been less money out-of-pocket for us, but the monthly premiums were higher.  We hoped that we wouldn't have any "major" issues that we would have to pay out towards our deductibles and co-pays this year.  WRONG ANSWER (that’s a whole other blog).   I’m looking over the EOB (see attached) and it states:  Total Charges: $160.00 (for an office visit only).  Amount Not Allowed:  $81.51; Deductible Amount:  $78.49; Amount Paid: $00.00 BUT THE BIG CLINCHER was on the messages:  *** It is your responsibility to pay:  $160.00*** There is a section on the EOB that says Physician Member:  NO.  Hmmm, before my husband chose his physician, he did his homework.  He went to the insurance website and made sure that he was a participating provider; which he was.  He presented his insurance card at his office visit to the receptionist.  There was nothing said to him that the doctor was NOT a participating provider.  So far, everything that he did was correct.  Now some people would just go, “oh well, I messed up, I need to pay the $160.00”.  Not me.  I could have called the doctor’s billing office, but I decided to get to the heart of the matter.  I went directly to our insurance company.  There’s a phone number at the bottom of the claim for customer service.  I had all my ammo ready.  I had the insurance card available, and had the insurance website up showing where the doctor was a participating provider.  After waiting on the line for about 30 minutes, I was able to speak with Tina.  She could not figure out why the claim wasn’t paid either.  She checked her information and saw that the physician was a participating provider.  She said she would send the claim back through for an adjustment (a fancy term indicating they would reprocess it) and it would take 2-3 weeks.  I documented the date and time I called, who I spoke with (Tina), the outcome (sent back for an adjustment) and asked for a “tracking number” for this call.  What went from possibly owing $160.00 went down to a $20.00 co-pay.  There could have been one other possible explanation for the insurance error.  Some physicians have two entities; i.e. John Johnson, MD and a group name, i.e. Johnson Family Medical Group.  Sometimes, not both are associated with the contracted insurance companies.  John Johnson MD may have a contract, but if the claim was billed under Johnson Family Medical Group, (who isn’t contracted) the claim would be denied.  If this ever happens to you, ask the insurance to reprocess it correctly.  If they won’t do this per your request, call the doctor’s billing company and ask them to resubmit a “corrected claim”.  I know I could use and extra $140.00, couldn’t you?

Do you automatically pay your medical bills when they come in the mail?

 Do you assume that your provider’s billers are posting the payments and adjustments correctly?  Have you ever wondered if you are getting billed for services that were not provided?  Do you wonder if you’ve overpaid on services and are due a refund, but not sure how figure it out?  Do the EOB’s (explanation-of-benefits) that come from your insurance company confuse you? I have worked in the medical field since 1978 and in the billing aspect since 1994.  I am not a certified billing coder, (who may be trying to optimize the highest reimbursement possible from insurance companies for their clients), but I am a consumer who is concerned about the rising cost of healthcare.  Every single day patients pay on their statements when no money is due.  They just assume because they get a bill that they need to pay it…..no questions asked.  Why would you pay for balances that are not your responsibility?  As a medical biller, I have made my fair share of mistakes.  When I was “learning” to post payments, I didn’t always take the appropriate adjustments when patients had one or more insurances.  After both insurances paid, if there was a balance, I just billed the patient.  No one double-checked my work.  Mr. X called me one day and asked why he still owed money on his deceased wife’s bill.  “After all” he stated, “you are contracted with both of her insurance companies.  Aren’t you supposed to take the highest adjustments regardless of who was primary and who was secondary?”  Sadly, I did not know this answer.  I went to my supervisor, who concurred with Mr. X and was told, “yes, take the additional adjustments”. What went from Mr. X initially owing over $300.00 (from the erroneous statement I sent him), changed to owing absolutely nothing.  Had Mr. X not questioned his statement, he would have paid money that was not due from him and no one would have known the better.  I know I could use an extra $300.00 on something other than medical bills, can you?  I’ve also learned to question my own families’ medical bills from early on.  When my daughter had a tonsillectomy, I could not believe the exorbitant fees the hospital charged.  Not knowing what to look for, I asked for an itemized copy of all the charges.  I then took this copy to the doctor that did the surgery.  He scrutinized the charges and saw that a surgical pack was billed twice.  The charge for each pack was over $400.00!  (That was back in the 80’s, now days it would be much higher.)  I immediately went over to the hospital billing department and asked them to correct this, plus I insisted that they send a “corrected claim” billing to my insurance company, so they wouldn’t inadvertently pay the duplicate charge in error.  Even more recently, my youngest daughter went to the emergency room for an infected ear.  I received separate EOB’s from both the facility and the treating physician.  Had I not understood what “split billing” was, I would have ran down to the hospital like a raving maniac and asked why they “double-billed” me. I'm in the process of writing an ebook/manuel to help the consumer understand their insurance billing and claims.  It's not designed to teach you a crash course in medical coding and billing, but to help you understand the process of what takes place in the insurance billing field, and the tools you can utilize if you feel you are wrongly billed.  In the meantime I've decided to post a weekly blog to help people with their billing questions. If you have questions or concerns, feel free to post them on the blog  (without giving away your personal information) or email me.  I'll try my best to answer your questions as quickly as possible, or direct you to resources that can help as well.