July 13, 2020

 Best Practices - Insureds

Process the Claim  


1. Follow health insurance plan rules - Check before your appointment. If you go to a network provider, you'll be charged only a fixed-dollar co-payment regardless of the size of the fee the doctor receives from your insurer. But for services for which you pay co-insurance—a percentage of the fee—price matters. Insurers have a separate contract with each of your providers that determines how much they will pay. So there's no single list of fees you can check. Ask for medical claims help if you need it.  

2. Get supporting documentation - Determine what form(s) need to be filled out, and get copies from the insurer.  Taking the extra time to locate the required forms will expedite the claims review process and boost the chances of prompt reimbursement.
3. Make copies of everything - Open a file showing not only what will be sent but also when and where it was sent. Make photocopies of not only the receipts but also the claim form itself and the instructions of any type of medical claims help that you may have received.  
4. Send claim form and supporting documents - Keep track of your treatmentsWrite down every lab, x-ray, diagnostic test and medication you receive. If you don't feel well enough to keep your own record, ask a relative or friend to do it. Even a limited list will make it easier to decipher your billing statements. Submit the claim form and documentation to the insurance company by certified mail, signature required 
5. Follow up - 

Review bills as they arrive. The first statement you are likely to get is an explanation of benefits (EOB) from your insurance company or a summary notice from Medicare. Either statement will tell you the total amount being charged for your procedures, the amount your insurer is paying, and the amount you owe in deductibles and copayments. Pay close attention to any incorrect data.

For instance, if your name or insurer's group number is wrong, the amount the plan covered is also likely to be. If you were in the hospital, see how many daily room-and-board charges are included. Many plans do not allow hospitals to charge you for your discharge day, although hospitals frequently do. And refer to your log for the time you were admitted. If you went to an emergency room but weren't admitted until after midnight, you shouldn't be charged for the previous day. Look for these errors:
  • Duplicate orders - This is particularly important for medications, lab work, or hospital-room fees. Compare the charges with your doctors' notes. Hospitals may bill a patient for a procedure even though a doctor canceled it. Also check the number of lab tests or procedures you had.
  • Unbundled fees - If you were charged for several lab tests in a day, for example, call your insurer to see if the charges should have been bundled under one lower fee. And look for the terms "kit," "tray," and "room fees." Each of those terms covers charges for several items, such as gloves, IVs, or sheets. You'll often find separate charges for those items such as a hospital bill for a delivery-room epidural kit that also includes an IV charge that should have been included in the kit fee.
  • Inaccurate operating-room times - If you had surgery, your anesthesia record will state the time your surgery began and ended. Operating-room use is generally billed at rates that vary from $69 to $270 per minute. You might find, for example, that you were billed 240 minutes for a procedure that took only 180 minutes, a correction that will save you thousands of dollars. Also make sure you were not charged for items that should be included in the operating-room fee, such as gloves, linens, or light covers.

  • Upcoding - This practice inflates the patient's diagnosis code to a more serious condition that requires more costly procedures, and can be the result of a simple clerical error or fraud. To spot it, compare the diagnosis on your doctors' orders and nursing notes with the charges on your medical bill.

  • Upselling - A charge can be needlessly inflated. For example, a doctor may order a generic drug for you that is readily available, but the hospital provides a more costly brand-name medication without your knowledge or consent, and bills you for it. Since you're not an expert at determining whether or not a drug is a generic and you may not have been in a condition to make that determination, you are not responsible for the increased charge.
If you find a mistake, call your provider. Ask for medical claims help from staff most familiar with your issue. Explain the error, and, if need be, ask someone in the billing department to make the correction. For each call you make, keep a record of the time, the name of the person you spoke with, and what you were told. Those may be the only steps you have to take to get the matter resolved. 

Related Resources:

1, "How to Audit Hospital Bill for Expensive Errors"Kathy M Kristof, L A Times (August 11, 1991)
2. "Best Way to Submit Medical Claims", Yahoo Voices (Feb. 1, 2010).

This describes an area in which medical claims help is often needed - auditing medical bills for accuracy. Judy Dugan of Consumer Watchdog discusses runaway medical bills and hospital's part in the problem.   

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