Healthcare Billing Guide:

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1 Healthcare Guide Healthcare Billing Guide: Strategies to Master Insurance and Billing Published by

2 Tips on Understanding Your Medical Bill 1 Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 2

3 Tips on Understanding Your Medical Bill In these turbulent economic times, consumers are becoming savvier spenders and healthcare is no exception. But paying for healthcare services isn t as easy as paying for other necessities like groceries or utility bills. Modern healthcare plans are incredibly complex, and for the average patient figuring out a medical bill can be a daunting task. Mark Rukavina, executive director of the Access Project, a nonprofit based in Boston that works to improve health and healthcare access, said one of the things his organization does is help patients understand their medical bills and what they owe to healthcare providers. In general, I think healthcare bills are confusing in part because when you have a procedure, you may be billed by a hospital and a specialty doctor or a physician group separately, says Rukavina. Know the Process for Better Outcomes Here s how the medical billing process works. After your scheduled doctor s appointment, surgery or other medical procedure, your physician submits a bill, or a claim, to your insurance company, Medicare or other insurance provider, for the services that you received during your hospital stay or doctor s appointment. The insurer then determines if and by how much it will reimburse your doctor or hospital for those services. When an insurance company reimburses a healthcare provider, the insurer typically sends a patient an Explanation of Benefits, also known as an EOB, which lists what services the insurance company is paying the doctor or hospital for and what services it is not paying for. The important thing to remember is that an EOB is not a bill. While many insurance companies send EOBs, not all of them do. Instead, you might receive a list of services performed once you leave a doctor s office or testing site. Not all doctors offices send statements. You may receive this document, an EOB or both. The most important document, of course, is the bill the doctor s office or health facility sends you. This will often come in the mail after the EOB and will reflect the charges that you owe once your healthcare provider has submitted a claim to your insurance company. The following are the main parts of your medical bill: Statement date: The date the physician s office, hospital or other health care provider printed the billing statement. Previous statement balance: The total amount of unpaid medical services before you received your current statement. If this is your first time visiting a certain doctor or other healthcare provider, or if you have no outstanding balance to your current healthcare provider, this column will appear as.00. Description: The list of services you received from your doctor or other healthcare provider. Account balance: The amount of money you owe to your healthcare provider. Once look over your bill, you ll want to compare it to your statement of services you received from your healthcare provider or the EOB you received from your insurance company. Check your bills for things like whether the dates on the bill and EOB match up and whether your insurance provider has paid your healthcare provider already. If more than 60 days have passed since your appointment or procedure and your insurer still hasn t paid your healthcare provider, you Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 3

4 Tips on Understanding Your Medical Bill should contact your insurance provider at once. For patients and their caregivers like patient advocates who have trouble managing their healthcare expenses, Wayne Messer and Associates, a financial services firm in the Chicago area, suggests that consumers consider using a computer software program, such as Intuit s Quicken Medical Expense Manager. If you can t pay the entire balance of a bill all at once, most hospitals and other healthcare providers can help you set up a monthly payment plan. Many states also have laws that protect consumers against certain debt collection and billing policies. Families USA, a consumer advocacy organization based in Washington, D.C., has compiled a list of consumer protection legislation that various states have passed: The organization has also published a guide for patients struggling with medical, which can be downloaded here: coping-with-medical-debt.pdf. As a resource, download an example of a medical bill from resource/resmgr/pdf_resources/medical_billing_example.pdf. Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 4

5 Top 7 Insurance Billing Errors, and How To Avoid Them 2 Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 5

6 Top 7 Insurance Billing Errors, and How To Avoid Them Costs of healthcare services and insurance plans are becoming increasingly more expensive not to mention much more confusing but there are ways to find savings and spot inaccuracies on your medical statements if you spend enough time reviewing your bill. A June 20 report by the American Medical Association found that commercial health insurers have an average claims-processing error rate of 19.3 percent, an increase of two percent compared to last year. The increase in overall inaccuracy represents an extra 3.6 million in flawed claims payments compared to last year, and added an estimated $1.5 billion in unnecessary administrative costs to the U.S. healthcare system. The report estimates that eliminating health insurer claim payment errors would save $17 billion nationwide. You can catch or avoid medical these billing errors by reviewing your healthcare claims whenever you receive them. Often physicians offices and hospitals may not have the time to review your medical bills in-depth. But as a patient advocate (whether your own or another s), you have a right to follow up on your medical bills and ask questions about any charges that don t seem correct. Here s a list of some of the most common inaccuracies in medical billing and claims processing. Services rendered: Are you aware of all the services that you received or medications you were given during a hospital physician s visit? Check your bill to make sure you were not billed for a service or medication that you did not receive. Double billing: Were you charged for the same service twice? Make sure you know what tests, procedures and medications you received at the time of a hospital or doctor s visit. Compare your knowledge to services outlined on the bill to ensure accuracy and prevent duplicate billing. Length of stay: Do you remember when you admitted to and discharged from the hospital? Compare those dates with the ones on your medical bill and contact the hospital if there is a discrepancy. False room charges: What kind of room did you stay in? Was it private or semi-private? Many hospitals now have plenty of private rooms, but if you shared a room with another patient, make sure you were not charged for a private room. Keyboard error: As hospitals and other providers move to electronic health records, most medical documentation is now completed on a computer by physicians, nurses and other staff members. But just because this process is computerized does not mean it is free from error. A typing error could cost you hundreds or thousands of dollars for a service that you did not actually receive. Review your bill for these types of errors. Operating room time: Hospitals or outpatient facilities may document more time that was spent in the operating room than was actually used. You have the right to compare this time to the records documented by your anesthesiologist. Canceled orders: Sometimes a physician or other healthcare provider may initially order you a test, procedure or other service and cancel it later if it is not needed. Again, make sure you were not charged for a service that you did not receive. Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 6

7 How To Appeal an Insurance Claim Denial 3 Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 7

8 How To Appeal an Insurance Claim Denial If an insurance company has denied payment for a patient s claim for a certain medical service, it may be necessary for the patient to appeal that denial. Any claim denial can be appeal by a patient but patients first need to familiarize themselves with the process. First, patients should contact the health insurer through the customer service line and explain the nature of the claim and the denial. If the issue cannot be resolved over the phone, the insurance plan will likely require the patient to submit an appeal in writing. Patient advocates can play a role in helping patients through this process if they re unfamiliar with how to write an appeal letter. Here are some easy steps to appeal a health insurance claim denial: 1. Read over your health insurance policy. Make sure you know what healthcare services are covered by your insurance and which are not. Having a firm understanding of what your insurance policy covers is the first and most important step when trying to appeal a claim denial. 2. Call your insurance company to determine what documentation you will need to appeal the claim denial. Keep a log of who you talk to, what they say and the steps you will need to take to carry out the appeal. Also note the date and time of your call, the length of the call and any other details of the conversation. 3. Write the appeals letter, indicating today s date and date of service, claim number, your member or subscriber identification number, group or policy number, amount of charge and a description of the medical service or services you received and the denial. Make sure to indicate what it is you are actually requesting. You letter should be concise and easy to read and understand. Include copies of important information like medical bills, documents for the appeals process and records of the steps you took before sending the appeals letter. 4. Before sending your letter, have your physician or a patient advocate help you with your appeal. Along with your letter and other documents, include any other supporting documents from healthcare providers like medical records, progress reports or other health reports that could strengthen the likelihood of winning your appeal. 5. Identify the address to send an appeal letter. The appeals address may be different that the insurance company s headquarters or the address to which the claim was initially submitted. 6. Send your letter through the mail and request a return receipt so you can prove that you mailed the appeal letter in a timely fashion. 7. Follow up with your insurance company. The appeals process can take weeks and even months, so call or your insurance company often to check on the status of your appeal. Make sure to take notes of each time you try to contact your insurer. For more guidance on how to craft your appeal letter, check out these sample letters: Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 8

9 Insurance Gaps Prove Dangerous for Diabetics 4 Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 9

10 Insurance Gaps Prove Dangerous for Diabetics Interruptions in health insurance coverage can mean irregular and incomplete care for diabetes patients, according to a new study. When patients with diabetes have less coverage or go in and out of the health insurance system, they are less likely to receive the screening tests and other healthcare services they need to treat the disease. A new Kaiser Permanente study released Jan. 4 found that this is true even when patients receive free or reduced-cost medical services at federally funded safety net clinics. Our study shows that patients need continuous health insurance coverage in order to ensure adequate preventive care, even when that care is provided at a reduced cost, Dr. Rachel Gold, lead author and investigator with the Kaiser Permanente Center for Health Research in Portland, Ore., said in a Kaiser press release. Many services at safety net clinics or community health centers are free, but some diagnostic tests and other services require a co-pay, which are typically covered by Medicaid. But for patients who lose their Medicaid coverage, testing is often delayed because they can t afford the co-pay. The Kaiser Permanente study surveyed 3,384 diabetes patients receiving medical care from 2005 to 2007 at 50 federally qualified health centers in Oregon. These community health centers provide free or reducedcost care to low-income patients whether or not they have health insurance. More than half the patients included in the study 52 percent had continuous health coverage when the study began in 2005, most often provided by the state s Medicaid program. Another 27 percent had no insurance, and 21 percent had interrupted coverage, during the three-year period of the study. Patients with private insurance were not included in the study. Most patients included in the study were aged 19 to 65 years; there were more women than men; about one-third were Hispanic; and almost three-fourths of the study participants were from households below the federal poverty level. Researchers looked at patients electronic health records to determine whether they received four services recommended at least once a year for sufferers of diabetes. Those four services included a lipid test for high cholesterol, a flu vaccine, a test that measures blood sugar levels and a urine test that can detect kidney damage. Out of the patients studied, 48 percent with uninterrupted insurance coverage received at least three lipidscreening tests at one of the study clinics from 2005 to 2007; 25 percent with continuous coverage received three or more flu shots; 72 percent received three or more screenings for blood glucose; and 19 percent received three or more screenings for kidney damage. Among the patients with partial insurance coverage during the study period, 44 percent had coverage for 80 percent to 99 percent of the three-year study period; 26 percent had coverage for 60 percent to 79 percent of that time; 9 percent had coverage for 40 percent to 59 percent of the time; 12 percent had coverage for 20 percent to 39 percent of the time; and 8 percent had coverage for 1 percent to 19 percent of the study period. In almost all cases, diabetes patients with no coverage and those insured for 1 percent to 99 percent of the study period received significantly fewer recommended health services than patients with continuous health insurance coverage. Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 10

11 Notably, the study showed no increase in services received as insurance coverage increased. Instead, all patients with irregular health cover were equally vulnerable to missing services, compared to the continuously insured. The study concluded that safety net clinic patients need both access to primary care and continuous insurance in order to receive proper preventive care. The study was funded in part by the National Institutes of Health and findings published online in the Journal of the American Board of Family Medicine. Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 11

12 Healthcare Billing Guide: Strategies to Master Insurance and Billing patientadvocatetraining.com 12