Insurance Claims – Industry Problem or Provider Calamity (Part 1)

Have you spent time reviewing your medical bills, insurance claim forms (like the explanations of benefits), or insurance contracts to know if you are really getting what you pay for?

With the Affordable Healthcare Act (“Obamacare”) passage in 2010 and implementation in 2013, reports show more Americans are using health insurance than ever before. With an uninsured percent of less than 10% of Americans, the number of claims submitted to insurance companies has increased as well.

Wouldn’t it be wise then,  as consumers as well as patients, to make sure that in a paperwork and electronic tangle of co-payments, deductibles, covered services, co-insurances and maximum out of pocket expenses, that we make sure nothing slips through the cracks?

I mean, the AHA has more than 2000 pages, and I’m pretty sure my health insurance plan does too! Recently I experienced a billing and insurance claim nightmare I’d like to share in an effort to encourage once again, for each of you to always be your best healthcare advocate.

The Story Begins…

As a divorced parent, insurance claims can be a bit more complicated.

My children have coverage from their father and their stepmother. While dual insurance has been a tremendous benefit through the years of braces, bronchitis and broken bones; sports accidents and “boys will be boys” injuries, it also adds a layer of confusion.

Which is primary?

What percentage gets paid?

Which contracted rate (assuming a payer contract was signed) and allowable amount apply to the services provided?

It’s overwhelming at best. Suffice it to say, however, that with the kids nearly grown and almost a decade of experience, we have gotten a pretty good handle on this aspect of co-parenting.

One thing insurance companies may provide is online access to benefits; most even offer a “pre-authorization” estimate for your out of pocket costs.

On the day of the procedures, November 7th, I was quoted an out of pocket amount due to the provider and promptly paid that amount (over $1,500.00).  When the children’s father learned the amount, he questioned it; based on his research on the insurance portals, our out of pocket should not have exceeded $250.00.

We were informed that only one of the available insurances would be billed and that was why the amount was so high. Without hesitation we agreed to file the secondary claim ourselves.

Providers are given certain information for the purpose of submitting claims not available to patients. Four days after the procedures, my former spouse went to the office, with the completed paperwork, to get their signature and other information.

After some questions about the billing process, the conversation became less than amicable. The surgeon intervened and offered for his office to complete the billing for both. This seemed to be a good idea and it was left with them to handle.

Life Lessons

This is a good place to push pause. Trusting the professionals is a lesson many of us were provided by parents and well-meaning mentors at a young age, but this might not always be the best advice. I’ve learned to follow a slightly different method – trust, but verify.

On November 11th, we agreed to trust the professional. More than sixty days later, I am still not financially whole, we’ve traveled down a less than pleasant road with our children’s healthcare provider, and now I’m faced with the dilemma of trusting my gut or trusting the professional. All because I have chosen to trust, but verify.

I’d like to offer my take on where I fell short in this process.

First, I should have been prepared with my own copies of the estimated benefits. Knowledge really is power and in this particular instance, the knowledge was available to me and I was not prepared with it.

Second, I should have asked the provider to provide me the information they received estimating benefits payable that was used to calculate my estimated out of pocket. This is when I would have learned about the difference in the amount billed to me, the amount submitted to the insurance company (-nies) and the negotiated and allowed amounts.

Then, I would have been prepared to negotiate what I was made to pay up front. Less money out of pocket may have made this extended timeframe without reimbursement much more palatable.

Next time

In my next installment, you’ll learn about balance billing, incomplete or inaccurate claim submissions and insurance denials. If you or someone you know has been injured as a result of someone else’s neglect or you believe you are a victim of insurance fraud or questionable medical billing practices, we may be able to help. Contact our office immediately at 941-748-2916 for a free attorney analysis of your case.