Healthcare Insurance Uncategorized

What you can expect to pay on your healthcare claims

Recently, we’ve received numerous calls from everyday folks, just like you, who have had medical treatment and aren’t sure what to expect as it relates to their claims.  More to the point, they want to know how much are they going to owe.   The answer to this question is based on which category of patient you fall into financially.  The answer varies depending on the answer to these questions.  Do you have insurance?  Do you have any other third-party who might take responsibility for your claim?  Other third-parties are Medicaid, Medicare, TriCare, Worker’s Compensation or the “Healthshare Ministries”.  If you have no insurance or one of the other third-party companies, then you are considered, “Self-Pay”.

In this post, I will deal with patients who have insurance.  I will cover the others in later posts.  So you need medical care?  If you need emergency treatment, don’t worry about the finances, in-network or out-of-network, go to the nearest Emergency Room that can handle your condition.  By law, your insurance company must treat all emergency visits to an Emergency Room as in-network.

When you walk into your provider’s office, any provider, they should ask you the same question I did.  Do you have insurance?  If so, they will have you sign an “Assignment of Benefits”.  You may not recognize it, but buried in all the paperwork somewhere is a statement that says, you are giving them the right to bill your insurance company directly.  Many years ago, it was typical to see a provider, pay that provider, get a receipt of payment and then send that receipt into your insurance company for reimbursement.  This process can still be done, but not recommended.

If a provider doesn’t collect an Assignment of Benefits from you and expects you to pay for their services up front, it is usually because they know, insurance doesn’t cover their services.  Chances are good they have tried in the past to get paid, and the insurance companies have decided the services they provide aren’t medically necessary or follow the standard treatment of care.  Tread carefully with these providers.

So here are the steps with comment:

1.) Once you have received the care you went in for, the provider will generate a bill and send it to your insurance company.

2.) The insurance company will process the claim.  In most states, there are “Prompt Pay” laws, which require the insurance company to process or adjudicate a “clean” claim within a specified period of time.  In Texas, it is 45 days.

3.) To process the claim, the benefits you have paid for via your premium will be applied to the bill.  This is where your deductible and co-insurance come into play.

4.) Once the claim has been processed according to YOUR benefits, an E.O.P. (Explanation of Payment) is sent to the provider along with payment (if applicable).

5.) At the same time, an E.O.B. (Explanation of Benefits) will be sent to you explaining how the insurance company applied your benefits to that claim.  THIS IS NOT A BILL.

6.) Each claim is handled separately, therefore there should only be ONE E.O.B. for each bill sent by a provider.  A provider can send multiple bills for multiple dates of service.  Therefore, you may receive multiple E.O.B.s.

At this point in the process is where the providers and the patients get into trouble.  Just because your insurance company has processed a claim, doesn’t mean it is correct.  If you or the Provider don’t feel the insurance company should pay something they didn’t, you can appeal it.  Your insurance claims department has a lot of goodhearted people who want to do the right thing, but the insurance companies put such pressure on them to move claims out the door, many things get overlooked.  In some cases, they didn’t pay because they need more information, which the provider must respond too.  

7.) If you and your provider feel the insurance company has adjudicated your claim correctly, then expect a bill from the provider.  You will be expected to pay the amount on the bill.  By law, providers must make three (3) attempts at collections.  What does that mean?  There isn’t a hard and fast definition.  For many providers, they simply mail out three bills and that is the end of it.  Some, turn you over to collections after the three “attempts” and some actually call before turning you over to collections.  It just varies by provider.

The billing process is now complete.  I welcome any questions or comments.  I can be reached at 512-417-6058.


Insurance is like a flashlight

Just like a flashlight, don’t really care if it works or not when there is plenty of light.  That changes when it gets dark.  When you turn it on, you count on it working.

Healthcare Insurance

It makes me MAD

During the Open Enrollment, I’ve talked to hundreds of people.  Some are getting conned by bad insurance agents.  I call them bad because they either don’t know, don’t care, or are just plain crooked.  If you bought a Short-Term plan or an Individual PPO (Preferred Provider Organization) and the Agent didn’t explain the difference between a Qualified Health Plan and the one you bought, then you’ve dealt with a bad insurance agent.  You will have to pay the penalty next year for not having a Qualified Health Plan.

A Qualified Health Plan has 10 Essential benefits included in them.  The others do not.  Be sure to ask before you buy!



Healthcare Insurance

Open Enrollment is Almost Over!

You have until this Friday, the 15th to select a health insurance plan, without answering any health questions.  According to Forbes and the Motley Fool, “medical debt is the No. 1 source of personal bankruptcy filings in the U.S.”  Having health insurance can help you avoid this.  Don’t delay.

Call us with any questions, 512-417-6058.


How to get a PPO!

If you’ve been trying to get insurance during the Open Enrollment, which ends December 15th, you have probably noticed you can’t get a PPO or Preferred Provider Organizations.  PPOs are only offered in the Small and Large Group markets.  The reason why is a topic for a future blog.  This topic is about how to get one if you are looking for insurance.

A small group in the State of Texas is defined as 2 to 50 employee lives.  It can’t be husband and wife, and it can’t be formed for the purposes of getting insurance.  The husband-wife thing has to do with participation.  Insurance Carriers in Texas require that 75% of eligible employees participate in the health plan, or they won’t insure you.  Having said that, a couple of insurance companies will waive the participation rates and allow a husband and wife to apply for insurance as a small group.

First, you must have a company.  A company would be an LLC, C-Corp, S-Corp or any other legal entity recognized by the State.  The company must be registered with the Secretary of State’s office.  A DBA (Doing Business As) doesn’t count.

The advantages are:  You have access to about 5 times as many plan choices including PPOs, the premiums paid are 100% deductible from the company, sometimes they premiums are cheaper and providers are more willing to take a group plan versus an individual plan.  Why providers don’t want individual insurance is a topic for a future blog.

If you think you might qualify and want to see how it might look for you, give me a call  I can answer all your insurance questions.

Ken Stephenson, MBA, FHIAS – 512-417-6058


Another Healthcare Law that Sounds Good but does No Good

In 1986, Congress enacted the Emergency Medical Treatment and Labor Act or EMTALA.  In 1994 they revised the Act to include the “prudent layperson” definition as a standard for evaluating whether a patient has an emergency condition.  Boiled down, it says if you think it is an emergency, then it is to be classified as an emergency.  It goes on to stipulate that payment is to be made for the initial evaluation and examination based upon the nature of the patient’s presenting complaint.

This federal law supersedes state law as it pertains to emergency healthcare and insurance companies.  So if you present to an Emergency Room (free standing or connected to a hospital), it doesn’t matter if it is in-network or out-of-network.  It is supposed to be paid for by your insurance company as though it were an in-network provider.

In Texas, we passed a law this year, Sponsored by State Representative Dr. Tom Oliverson (R-Cypress), HB 3276, that requires ERs to post notice of what, if any, insurance networks they are in.

Here is my question.  If ER visits are supposed to be treated as in-network, regardless of their network status.  Then why do we need a law requiring them to post a notice of what, if any, insurance networks they are in?

Healthcare Insurance

What is an “Oscar”?


There is a new entrant into Travis County for insurance.  It is called, Oscar.  Those of you looking for health insurance are very limited in your choices.  For years, Blue Cross Blue Shield has really been the only viable choice.  Now that Oscar has emerged, Blue Cross Blue Shield has some competition.  Let me briefly explain what they do differently.  Blue Cross Blue Shield only offers an HMO or Health Maintenence Organization.  What most people don’t like about HMOs is having to get a referral to see a specialist.  Oscar offers an EPO (Exclusive Provider Organization) which doesn’t require referrals to specialists.  Blue Cross Blue Shield offers Telemedicine, but charges you a PCP (Primary Care Physician) copay everytime you call.  That could range from $30 to $60 depending on the plan you chose.  Oscar does not charge a copay for Telemedicine phone calls.  Call every 5 minutes if you want.  Additionally, Oscar offers a concierge team responsible for answering your questions.  It is the same 4 people that you deal with and they know who you are and your history.  Blue Cross Blue Shield would ask that you call Customer Service and repeat your story multiple times to different people.  If you would like to see what Oscar might cost you and your family, drop me an email at or call me at 512-417-6058.



Are you ready?

Open enrollment for individual and family insurance for 2018 begins on November 1, 2017, and runs through December 15, 2017.  After that date, you will no longer be able to get insurance without any questions being asked.

It costs nothing to use a broker or agent.  Don’t just by the cheapest insurance.  It could cost you in the long run.  Have a licensed agent explain to you what it does and DOES NOT cover before you buy.

© 2017 by VersaClaim, Inc., all rights reserved.

Healthcare Insurance

Did you lie about having health insurance on your tax form?

You don’t have to answer that, but on April 15, 2016, when you file your 2015 taxes, the IRS will know if you had a QHP or Qualified Health Plan or not. Insurance Carriers are now supposed to collect your Social Security number and report it to the IRS has having health insurance.  They have typically collected this information, but now they have to report it to the IRS.  If they don’t, they will be out of compliance.

Here is how it will work.  Next year, when you file your income tax, if your social security number doesn’t pop up as one reported by an Insurance Carriers as having a Qualified Health Plan, you will be receiving an inquiry from the IRS.  You’ll either have to submit proof you did have a QHP or pay the fine.  If you don’t have coverage in 2015, you’ll pay the higher of these two amounts:

  • 2% of your yearly household income. (Only the amount of income above the tax filing threshold, about $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a bronze plan. Or $325 per person for the year ($162.50 per child under 18). The maximum penalty per family using this method is $975. –
  • Open enrollment is over, but there is one way you can get health insurance without any health questions being asked.  You have until April 30th to take advantage of this “Special Enrollment Period,” so don’t delay. Go to: to run a free quote and find out what it might cost or call me to discuss at 512-301-4442.

© 2017 by VersaClaim, Inc., all rights reserved.

Healthcare Insurance

What Most People Don’t Know About Deductibles

In addition to selling insurance I work with Providers helping them understand all the new regulations and how the Affordable Care Act will affect them. Recently I spoke with a Medical Biller about provider charges, the incredibly high deductibles patients must meet for their insurance plan and what Payer consider to be an allowable service. This particular Biller suggested Providers raise their charges to astronomical levels so patients will reach their deductible faster. This is absolutely wrong and here is why.

The three terms we are discussing here are: Charges, Deductibles and what the insurance companies and Medicare call the Allowable. A Provider can charge whatever they want to Charge for their services. The industry standard is usually 2 or 2 1/2 times whatever Medicare or the Center for Medicare and Medicaid Services (CMS) will pay. You will see the charge, because that is what the Provider puts down on the claim.

We should all know what the Deductible is. That is the amount you typically have to pay before your benefit plan will start paying towards your claims. In the recent healthcare climate, that could be as much as $6,350.

The Allowable is what the insurance company or Medicare deem covered under your benefits and what they will pay for that particular service. Please note that not everything included on your claim from the provider is deemed allowable.

When insurance companies calculate whether or not you have met your deductible, they do it using the allowable amount, NOT the charged amount. Therefore, it really doesn’t matter what the Provider charges, only what the insurance company deems allowable.

If your deductible is $3,000 and the charges are $20,000 but the insurance company only allows $1,000 of it to be paid, then you will still have $2,000 to pay before your deductible is met.

If you are dealing with an in-network provider, you don’t have to worry about “balance-billing.” Balance billing is the practice some providers (who aren’t in network) use to collect the difference between the charged amount and the allowed amount.

I hope this helps clear up some of the confusion. I will post more about how claims are handled and what is expected from you the patient, your insurance company and the provider. Go to to find out more about what can be done with out-of-network claims.

© 2017 by VersaClaim, Inc., all rights reserved.