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Do you become frustrated and overwhelmed managing your medical bills and your health insurance claims? Are you stressed out by having to tell your story over and over again each time you call your insurance company? Are you paying bills that your insurance company should be paying? Do you have problems getting refunds from providers when both you and the insurance company have paid?
Because of the constantly changing health care marketplace and its cost control procedures, more people are unwilling to deal with the complexities of the bureaucratic red tape. As a result, many do not maximize their reimbursement and leave money on the table. Whether it is a busy executive, an employee, employer, senior citizen, a child taking care of a parent or grandparent, the need to avoid an unnecessary loss of benefits reimbursement becomes meaningful with today’s high cost of health care.
Here are some helpful hints to get you through the red tape, give you peace of mind and hopefully more money back in your pocket:
1. Ask the doctor’s office file your claims
Whenever possible, have the doctor’s office file your claims and accept assignment. If they accept assignment, they agree to file the claim and accept the amount the insurance company approves as payment in full. They cannot bill you for the difference between their charge and the approved amount. In most cases, the insurance company will pay the provider directly. Your only obligation usually is the coinsurance. Many providers may ask for this coinsurance at the time of your visit. Try to have them bill you for this; pay after they have filed the claim and been paid by the insurance company. Many people overpay the coinsurance, for example, 20% of the charged amount instead of 20% of the approved amount and never get a refund.
A provider who doesn’t accept assignment may bill you the full charges regardless of the approved amount. He is not obligated to file the claim, and the insurance company usually pays the patient directly. In the case of Medicare, however, the provider must still file the Medicare claim even if he does not accept assignment and is not required to file any secondary insurance. He cannot charge the patient more than 15% above Medicare’s approved amount. Medicare will pay the patient directly as will the patient’s secondary/Medicare supplement insurance.
2. Give all the necessary information
If you have more than one policy, don’t assume the provider will file the claim. If you have to file, give the insurance company all the necessary information. Incorrect or missing information will only cause a delay in processing. If you need to submit an itemized statement, include the following:
- Description, charge, date and location for each service
- Name of the provider who treated you
- All appropriate insurance numbers
3. File claims promptly
File claims as soon as possible. Don’t let bills or receipts pile up and certainly don’t save all your claims until the end of the year. If you’ve paid the provider up front for services, file quickly to receive your reimbursement. The timely submission of claims is critical for reimbursement. Even if your provider agrees to file the claim, be sure it is filed within the filing time limits imposed by the insurance company. Claims filed too late often result in a bill to you for services that should have been paid by insurance.
4. Make sure bills are final
Don’t pay bills unless you are certain they are final. Never pay a bill until you’ve received the explanation of benefits from your insurance company. Bills are often sent prematurely, and many patients pay before knowing whether the provider has received a payment from the insurance company. Duplicate payments to providers are rarely refunded to the patient. When you do pay a bill, keep records by date of payment and check number. This is necessary in case you receive a duplicate bill indicating that payment hasn’t been received.
5. Understand your benefits
Know your benefits. A lack of benefits knowledge very often leads to patients being billed and paying for services that should have been reimbursed or written off. Claims are rejected for what the insurance company says are non-covered services or because the provider submitted an incorrect diagnosis. Always examine the EOB to determine what was allowed and how much was paid. If you don’t understand why a service wasn’t paid, ask your insurance company and provider.
6. Appeal rejected claims
Appeal rejected claims regardless of the reason given. The provider could be helpful, especially if he has not received payment for the service and accepts assignment. Just because an insurance company says the charges exceed their allowed amount, that may not be correct.
7. Keep detailed records
If you have to file your own claims, make copies of everything you submit for easier tracking and follow-up. It will also facilitate resubmitting claims if the insurance company says it never received them.
The reasons for greater cost and complexity of the American health care system are varied but for the most part have to do with advanced technology and a highly bureaucratic system of red tape and record keeping. An unbelievable amount of money is spent on a paper chase of staggering dimensions to determine claims and payment, none of which adds one bit to the delivery of medical care. Don’t be intimidated by the system. If you are persistent and assertive, you will be able to maximize your reimbursement, minimize your stress and get peace of mind.