By Martine G. Brousse
"The Medical Bill Whisperer... and insurance stuff too"
Patient Advocate, Certified Mediator
June 6, 2023
In many years as a billing manager and now Patient Advocate, I have noticed that patients tend to fall into two opposite categories: The "trusting" types promptly pay whatever amount a bill indicates, while the "questioning" ones rarely do until a final or collection notice is sent to them.
Neither is really the best approach.
Here are some suggestions about when to pay and when to wait.
1. Get familiar with your policy
· Every year, at time of renewal, find out how much your liability amounts to. What is your yearly deductible (the sum you pay first before your insurer issues a payment)? What is the yearly out of pocket (also called “co-insurance”, it is your share of the cost before your insurer pays 100%). Any office visit co-pay? ER admit co-pay?
· Consult your insurance online account for a summary
· Throughout the year, see the met-to-date deductible and co-insurance totals online
· Call the insurance if your policy is unclear or confusing.
· Every balance listed on any medical provider's statement should match your insurance Explanation of Benefit (EOB). This EOB explains how a charge was processed and what your share of cost is.
· If the statement's balance matches the EOB's, you are likely responsible for this amount… as long as the insurance made no mistake!
· If it doesn’t, a call to the billing office and/or your insurance is in order
· A patient Advocate specializing in Billing can help confirm a balance, or help you appeal
3. If there is no matching EOB
· Was the claim sent yet and will it? To the right insurance?
· If visiting an out of network provider, or one that does not accept any insurance, you may need to submit an invoice or claim form yourself for reimbursement.
· A first statement may just be a notification of services rendered, not an actual bill
4. If your EOB does not match the bill
· Is the claim pending or denied by your insurance? The EOB will show why.
· Does your insurance need more info from you (other insurance coverage, dependent status, accident questionnaire) or from the office (medical records, authorization)?
· Contact the billing person for clarification. After all, mistakes happen.
5. What are your rights?
· to receive concrete explanations from your insurance carrier as to how a claim was processed.
· To file an appeal with your insurance if the terms of policy were not applied, if State or Federal mandates were ignored or if an obvious error has occurred. Detailed steps and specific forms are available in your policy booklet or online.
· To get details and justification for any charge billed to you by a medical provider. Don’t hesitate to contact upper management for concrete answers.
While ignoring a bill from your medical provider is never a good idea, paying up without checking the amount billed to you is not recommendable either.
Your insurance is your primary guide when determining if a bill is owed, and how much. Contacting the billing department is a must whenever you ask yourself “do I truly owe this and why?”
Martine Brousse, the "medical bill whisperer" is a Patient Advocate and Certified Mediator located in CA and the founder of AdvimedPro, which she started after 20 years as a billing manager for physicians.
(424) 999 4705 - F (424) 226 1330
@ Martine G. Brousse 2023
@ the medical bill whisperer 2023