Patient Advocacy: Healthcare on your side
by Martine G. Brousse,
Healthcare
Specialist, Patient Advocate, Certified Mediator
ADVIMEDPRO
from your medical providers?
In my professional career, I have observed that patients tend to fall into two opposite categories. The
"trusting" types always pay whatever amount is indicated, while the
"questioning" ones rarely do so until a final or collection notice is
sent to them.
The common excuses of the
latter types are their lack of trust in the amount billed or their waiting for
explanations (they usually do not request). The former trusts the billing staff as they do their doctor.
Here are some guidelines to
help you determine when to pay and when to wait.
1.
Check your insurance policy
Each January, find out
what amounts you can expect to ultimately be responsible for in the coming
year. What is your yearly deductible (the sum you pay first before your
insurer starts issuing payment)? What is your yearly out of pocket (your
percentage of the cost before your insurer pays 100%). Do you have an office
co-pay (set fee)?
Contact your insurance if the
terms of your policy are unclear or confusing.
2.
Verify and compare
Every amount listed on your
provider's statement (doctor, facility, imaging center, lab etc) should match
your insurance Explanation of Benefit (EOB). You can also go online to check
whether a claim has been paid, and what is your total liability. If the
statement's balance matches the EOB's: you owe this amount.
A spreadsheet at the time of matching statements
and EOBs is a great visual help for you, and for your tax person during tax
season.
3.
If you have not received an EOB
Further research may be
required.
Has the claim not been
sent? More medical offices no longer handle claims, leaving it to patients
to mail them. If you have been handed a claim form or an itemized bill, make
sure to forward it to your insurance for processing.
A first statement may
just be a notification or description of services rendered. Confirm a claim has
been processed before paying such a "notice".
Does the provider have your
correct information? If you received a new card, forward a copy to the office:
an identifying number or claim address may have changed. Charges may have
been denied for the incorrect info.
4.
If your EOB does not match
Is the claim pending by
your insurance for additional information? The EOB will indicate what is needed.
It could be required from you (info regarding another possible primary coverage,
verification of a dependent status, or return of a health questionnaire or from
your medical provider (address update, medical records). In this case, forward
a copy of your EOB to the billing department and demand prompt handling.
Consider calling the
billing person, to verify contractual adjustments were correctly applied, or
ask for justification. After all, mistakes happen. You may also contact your
insurance for explanations.
Is the provider "out
of network", meaning not within the contractual network your policy
covers? If this is the case, you will need to negotiate a settlement as you are
liable for whatever amount is billed to you.
However, if services were
rendered to you by an out-of-network provider at an in network facility or setting,
especially if you had no choice, an appeal to your insurance should be
fruitful. Your insurer, once informed you are being billed for the full amount,
would likely propose a financial settlement or issue additional benefits to
reduce, or cancel, your balance.
5.
What are your rights?
In case of any conflicting
or unclear paperwork, you are entitled, as a patient, to receive concrete explanations
from your insurance carrier. You may also file an appeal, and ask for a review
or reprocessing of any charge. Detailed steps and specific forms are available
in your policy booklet or online.
As your creditor, the
medical office has the burden to detail and explain any liability billed to
you. Although many do not, by choice or lack of understanding or training on
the part of their staff, do not give up. A call placed to an office manager or
doctor will usually resolve such issues.
Filing complaint to the
insurance company, a grievance to your state commissioner's office or medical
board is next.
In conclusion:
While ignoring a bill from your medical provider
is never a good idea, paying up without checking the amount billed to you is
not recommendable either.
Your insurance should be your primary guide when
determining if a bill is owed, and how much. Discussing charges with the
billing department is a right to exercise whenever appropriate.
© [2016] Advimedpro.
© [2016] Martine G. Brousse.
All rights reserved.
My
objective is to offer you, the patient, concrete and beneficial
information, useful tips, proven and efficient tools as well as
trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
AdvimedPro (424) 999 4705 or (877) 658 9446 fax (424) 226 1330
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