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.

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