Billing Problems: Who’s to Blame? Your Healthcare Provider or Your Insurer?

It would be nice if insurance paperwork were simple, if doctor bills were simple and easy to understand, and if questions or concerns could be cleared up with a phone call. It would also be nice if everyone had a robot maid to do the dishes, but we shouldn’t expect any of those things to start happening anytime soon. Instead, insurance paperwork is complex, billing problems persist, and those dishes just won’t clean themselves. Enough about dishes; we can’t help you with those. But we can help you understand the medical billing process so you’ll know where to turn if an error or dispute arises. At least, we can try.

After a visit to the doctor, the doctor’s office charges you a co-pay amount (or more if you haven’t met your deductible and required additional services) and sends a bill for the remainder to your insurance company, based on the information they have in your file. This is why they ask you every time you go whether your insurance has changed since your last visit.
At the insurance company, a claims processor goes over the invoice to ensure that the claim form has been filled out completely and correctly and that the service provided is covered under the terms of the policy. If everything checks out, the insurance company pays its portion of the bill by submitting payment directly to the doctor’s office.

Now the Fun Begins

If down the line you get a bill from your doctor for services you thought were covered, something might have gone wrong at any point between the doctor’s office and the insurance company. You’ll likely need to talk to the doctor’s office, the insurance company, or both, to straighten things out. Review your insurance policy beforehand so you are armed with correct information regarding your policy and what you should owe. Some of the questions that may need answering include:

• Did the doctor’s office apply the correct co-pay or deductible amount when charging you at the time of your visit?
• Was your visit covered by your policy? Were additional services provided during the visit that might be excluded under your policy?
• Did the billing department at the doctor’s office apply the correct code when submitting a claim to the insurance company? You might not know the answer to this question, but you can ask them to double-check that the claim was coded correctly. Coding errors are a common source of billing mistakes.
• Did the provider neglect to bill the insurer? Your claim might have fallen through the cracks, or the doctor’s office might have old insurance information on file. The possibilities are endless. If you don’t have an Explanation of Benefits (EOB) from the insurance company, then it’s likely they never got a claim submitted from the healthcare provider. EOBs should be mailed or emailed to you according to your preference, or you can review them by logging into your account on-line.
• Was the provider you saw in the insurance company’s network? If they were out-of-network, they might be unfamiliar with the process of submitting claims to that insurer. They also might not submit out-of-network claims at all but instead require you to submit an insurance claim yourself. In the best of worlds, the provider would let you know this on the date of service, but they might just expect you to know it yourself.
• The processing time for your bill might depend on whether the provider does its billing in-house or uses a third-party biller. Using an outside biller could delay processing time, but so could an in-house billing department that is overworked and less efficient than a third-party biller.

Make and Keep Records, and Get Help if You Need It

If you get a bill from the doctor’s office in the mail, and you thought you already paid your portion, you’ll likely have to spend some time on the phone with the doctor’s office and/or the insurance company. Document your calls by making a written memo to yourself, including the date and time of the call, whom you spoke with, and what was discussed. Also, keep all letters, emails or other correspondence you send or receive. These documents might be important later to prove your position.

If you are being billed because the insurance company denied your claim, then you have an entirely different kind of problem to deal with. Whether they say your service was not covered or excluded, or that the treatment or procedure was investigational, experimental, or not medically necessary, you should talk to an experienced insurance law attorney after any claim denial. If you try to take on the insurer through their internal appeal or review process on your own, you could make mistakes that jeopardize your case and keep you from getting an otherwise valid claim paid. Most insurance claim denial lawyers will talk to you for free and only charge a fee if they are successful getting your claim paid.
That was easy. Now, about those robot maids…