I pay SO MUCH for my insurance! WHY aren't they paying my claims???

Are you having trouble having your claims paid? Do you know why they're not being paid? Do you know what to do about it? Are you being told it's because the Provider was out of network? Will no one give you any answers? Maybe I can help you.

There are a lot of things that unless you've taken classes or have a lot of experience working in the medical field, you are not aware of and insurance companies are certainly not going to tell you. I will tell you right up front that you cannot always trust that they are correct in how they processed your claim; therefore if you have ANY doubt in your mind, please call them and ask as many questions as you can think of. They send you an Explanation of Benefits (EOB) which is supposed to explain how they processed your claim, but again unless you have the experience, you may not know how to read them or understand the lingo. That's why there are people like me here to assist you.




Everyone really needs to know how to read and understand their Explanation of Benefits (EOBs). So why don't we start there. Every insurance company has their own "style" but it all boils down to the same information. The "Submitted" or "Billed" amount is what the Provider (the one who rendered the services) submitted for payment. The "Allowed Amount" is the maximum amount that the insurance company will pay; it's what the "contracted amount" between the insurance company and the Provider agreed upon for the specific service or procedure (i.e. an MRI, X-Ray, Mammogram, etc). The "Adjusted Amount" is what the Provider has to write off due to the contract; it's the difference between Submitted/Billed Amount, what the insurance pays and what amount you as the Patient is responsible for. The "Deductible" is what you're required to pay out of pocket before the insurance company pays on the claim. Some insurances have lower deductibles which are around $200-$500. Then there are others which I consider outrageous that are $1000 . I've even heard of them being over $10,000. If you ask me, why bother having insurance? But anyway... For Deductibles, there are in network and out of network. You definitely need to pay attention to what they apply to which network. For instance, if you went to your regular Primary Care Physician (PCP) and you received an EOB showing that your deductible amount was applied to in network, then it's a legitimate application towards your in network deductible. If you went to your PCP and they applied it to your out of network, there is definitely an error. You need to know and keep track of how much your annual in network and out of network deductibles are EACH and keep track of how much has been applied to each of them. To do that, all you need to do is keep your EOBs. Those are your records of proof for many things; that a service was paid, how much was paid, how much was applied to what deductible, etc. Trust me, there are definitely times they come in handy. I guarantee there are times that these scenarios will occur:

* The insurance company will claim they didn't receive the claim, yet it was already paid.

* The insurance company already paid on the claim but the billing service hadn't posted the payment yet and sent you a bill; basically everything crossed in the mail.

*The insurance company paid, the billing company never received the payment but you received the EOB. The billing company and the insurance company can work together; if the check was never cashed they can put a stop payment on it and reissue it. If it was cashed, they can provide a copy, front and back with an EOB so that the billing company can update their records.

Bottom line, there are way too many scenarios for me to even put on this site, so let's move on.

Also on the EOB is "Deductible/Copay/Coins". This is Patient Responsibility meaning that it's your out of pocket expense that is being applied to either your deductible, copay or coinsurance. Some insurances lump these all together in one column, others separate the deductible from the "Copay/Coins". A lot of the time you'll pay your copay at the time of service but the billing company won't show that as already paid. If you were given a receipt or have a canceled check, be prepared to provide that to the billing company in order to have it applied to your account. Coinsurance on the other hand is completely different. Coinsurance is basically when the insurance company is splitting the cost of your insurance with you. For instance, if you have a 70%/30%, 80%/20% or 90%/10% split. As an example, say you have surgery on your leg and your plan design requires 90%/10%. Your insurance will pay the 90% and the 10% will be your responsibility; that's your coinsurance. Keep in mind, if you haven't met your deductible yet, this can be in addition to your deductible.

Another thing you definitely want to pay attention to on your EOB is the "Reason Code". This tells you why something was done or not done with your claim. Sometimes the Reason Code consists of just letters, just numbers or a combination of both. Then in another area on the EOB you'll find the Reason Code and see why your claim was denied or why one service or services were denied. You could end up receiving a bill from the billing company because "further medical information is needed in order to process the claim" or "the incorrect procedure code was submitted. Please correct and resubmit the claim". There are several Reason Codes that have nothing to do with why the Patient should be responsible for the bill but because of the way the system works at the billing company, the Patient will end up with the bill even though they are NOT responsible. Does the billing company care? No, not really. You would be very lucky to get in touch with one who had a rare Customer Service Rep, such as myself who would actually take the time to look into it for you. If you call and say, "I want to pay the balance on my account", and you actually have an open balance, 9 times out of 10 they will just take your money without asking you if you have insurance and without looking further into your account to see what activity has already occurred. Their main focus is the revenue for their client, not the Patient. I just left a billing service in April 2008 where I was a Customer Service Rep. The Patients calling in would constantly ask for me because my focus was the Patient. I was actually instructed to "lessen the quality of my work" which basically led to my separation from the company. But anyway, this is just one of the reasons why I know how these things work. So never call and say that you want to pay the balance on your account until you have verified that your insurance has paid all that they are supposed to pay.

What Kind of Plan Do You Have?

You need to pay attention to whether you have an HMO, PPO or POS. HMOs you need a referral from your Primary Care Physician (PCP) in order to see another Doctor that is either a specialist or out of your network. The referral will need to be provided to the specialist and your insurance company; otherwise they will deny the claim stating that no authorization was provided. If for some reason your claim gets denied for this reason, all you need to do is get a pre-dated authorization for the service rendered from your PCP, make sure it is provided to your insurance company and the specialist, then the claim will be resubmitted and you should be all set. Once the claim is reprocessed, all you should be responsible for is whatever copay/coinsurance/deductible is applied as Patient Responsibility. However, don't assume that any bill you receive is correct. Make sure you look every thing over thoroughly and I highly suggest that you call before paying anything.

If you have a PPO or POS, these are extremely similar. You can see any Provider or Specialist that you wish; it doesn't matter if they're in or out of network and you don't need a referral.

What if I have 2 Insurances and still get billed?

Senior Citizens, married couples, retirees or people on disability; a lot of them have two insurances. A lot of the time what's called Coordination of Benefits (COB) doesn't work the way it's supposed to. What is Coordination of Benefits? It's when you have 2 insurances and your primary insurance is billed, they pay their portion, then send the claim along with an EOB to your 2ndary insurance. For an example, say you're retired and have Medicare and AARP as your 2ndary, also known as supplemental insurance. First the claim is submitted to Medicare primary, then Medicare submits it to AARP with the EOMB (Explanation of Medicare Benefits). Medicare pays 80% then 2ndary pays, as a rule, the remaining 20%. But again, as I said, the COB doesn't tend to work as it's supposed to. So if you receive a bill and you know you have insurance, DON'T JUST PAY THE BILL!!! Call and make sure that your insurances were billed and they were properly billed. If they were both billed and for some reason were rejected, WHY were they rejected. One major rejection I can think of off the top of my head is this: Medicare paid then it was submitted to 2ndary. 2ndary rejected because the Medicare allowable amount was greater, basically meaning greater than the 80% was paid by Medicare. Therefore, they won't pay anything further and the Patient is responsible for the balance. Another thing that 2ndary insurances won't pay for when you're on Medicare is when Medicare applies a balance toward your deductible. You will be responsible for that balance as well.

I'm Married and we BOTH have insurance through work. Which one is Primary?

When you're married and you both have insurance through work and you carry each other on your policies; if the service provided is for you, you use your insurance primary and your spouse's is 2ndary. This will ALWAYS be the case, NO EXCEPTIONS. Therefore, if the service provided is for your spouse, THEIR insurance is primary and YOURS is secondary.

If I'm on Medicare and Medicaid (Medicaid is ANY State Funded Medical Assistance; i.e. Mass Health, Title 19, Saga, Husky, Healthy Kids, etc), Can I be balance billed?

The answer to that is ABSOLUTELY NOT!!! Whatever Medicare and your state aid does not pay HAS TO BE WRITTEN OFF. So if you have these kinds of coverages and still receive a bill, don't just let it go saying, "Well, I don't have to pay for this, they have to write it off" because I guarantee it will end up in Collection Activity. What you need to do is call the billing agency and tell them that you have Medicare and Medicaid so the balance needs to be written off. If you let it go and it ends up in Collection, it can be considered negligence on your part and you can be held accountable. They can prove that they billed you numerous times and you never responded.

Just a note about Medicaid: Medicaid will ALWAYS be the last insurance billed. If you have 3 insurances, Medicaid will be third. If you have six insurances, Medicaid will be sixth. In other words, Medicaid will always be the very last insurance to be billed.

I went to an In Network facility but received two bills and one of the bills was processed as Out of Network? Can they do that?

Only if you let them! Have I got news for you!!! Keep reading because I guarantee it will be worth it!!!

This is exactly one of the things that I was talking about in the beginning that the average person wouldn't know about. This type of situation would occur if you went to a hospital and had a service such as an MRI, X-Ray, Mammogram, CT Scan, Ultrasound, etc. Some sort of Neurology, Cardiology, Radiology, etc. What will occur is that you will receive a Facility bill; this covers the use of the hospital and all of the equipment used. This will be the charges that are definitely In Network. The other bill will be the Physician Fee which covers the reading of the results of whatever services were rendered. More times than not, the Physician Fees will be processed as Out of Network because that Provider and/or Group does not accept your insurance. Allow me to elaborate...

Hospitals are mandated to accept any and all insurances, but individual Providers and Groups are not. Now, you will receive a bill from the Hospital, let's call it the Renowned Beth Israel. Their bill will be processed as In Network because they are mandated to accept all insurances. You may be required to pay a copay. However, let's say you were there for an MRI and you received a bill for the Physician Fees and let's name that Group The Medical Miracle Workers (Only because I don't know of any Medical Group named that so I can't be sued!). That claim was processed as Out of Network; in this case it could have been completely rejected leaving the full balance as your responsibility or they only paid a very low amount leaving you with a very large balance. Now here's the real kicker; the part that 99.9% of people don't know about and the insurance companies won't tell you so a lot of people end up paying the bill. I'm going to tell you how to have your insurance company pay that balance for you and more than likely leave you with NO BALANCE!!!

All you need to do is call your insurance company and tell them this: You went to an in network facility, therefore you were under the impression you would be dealing with all in network providers. You don't have any choice as to who reads the results of the services you receive, therefore they need to reprocess the claim(s) at in network rates. They will reprocess the claim(s), then all you need to do is call the billing company to let them know that they're reprocessing so they can note the account. If you continue to get bills, especially if they're Pre-Collection letters, DEFINITELY call your insurance company first to find out what's going on with the claim for the date of service specified on the bill, then call the billing service to update them. That way, they can do what's called "Resetting the statements". This will prevent any collection activity. Always remember that communication is the key.

In regards to your copay when receiving these billings, you are only required to pay ONE copay. Therefore if you paid a copay for the hospital bill and you receive a bill for the Physician Fee and it was applied towards your copay, that will need to be adjusted, showing that you paid it already. You are only required to pay ONE copay per service rendered.

Medicare Managed Plans

Medicare Managed Plans are insurance plans for Senior Citizens/Retirees that are with regular insurance companies such as Aetna, Cigna and Blue Cross. They cover their medical claims as well as their prescriptions. Instead of billing Medicare the Managed Plan is billed. A supplemental plan is still a good idea to have in place for left over balances.

If you don't see the answer to your particular situation on my site, please email me at hope4pcofmind@yahoo.com. If I don't already know how to handle your problem, I will do the best I can to find out. I look forward to hearing from you!!! ~Wylene