A patient’s balance was drawn due to continued non-payment. The patient disputed that she owed the balance. The provider rebilled insurance and still received a denial. The following details of the patient’s benefit plan led to the denial:
- I needed a pre-authorization prior to service based on the codes/modifiers submitted.
- The service provided was classified as non-emergency care based on file documentation, which led to a prior authorization requirement.
- The provider was not contracted with the insurance company, which means they did not have to accept their allowable charge as payment in full and could bill the patient for the total uncovered balance of more than $1,500.00.
As you can imagine, the patient was extremely upset. He said that it was an emergency and that he experienced a lot of pain. Had he known all of the above, he would have selected an alternative service. He also felt that the provider should have told him all of this because it was his responsibility. He paid a lot of money to the insurance company just to get this unfair treatment.
Six Areas Patients Should Know
Regardless of health care coverage, it is your responsibility to learn the details of your plan coverage, and it is your responsibility to do so. Otherwise, you may end up in a situation like the one above. If you’re unsure about coverage or verbiage, ask for details. Also remember that insurance companies can also mistakenly deny charges. If you disagree with a health insurance decision, you have the right to appeal. Be sure to follow your insurance plan’s appeal process to get a timely response.
Here are six areas to check before medical service:
- Payment points such as copays, coinsurance, deductibles, and percentage of coverage due after meeting deductibles. There is a big difference between the amounts owed for an in-network service vs. out-of-network provider. Patients new to insurance coverage usually don’t know the difference.
- Where to go to navigate health plan information.
- Member Resources.
- How to stay in the network.
- Out-of-Network Payments.
- Covered preventive services.
Where can you find this information?
- Websites: All health plans typically have very extensive and increasingly sophisticated websites. For example, United Healthcare’s site lists prices, providers by zip code, and even if the provider is accepting new patients. Some of the information may be a bit out of date, but it’s a start.
- Documentation: Generally, by the first day of the year, health care plans send information about changes in insurance for the following year. It’s easy to find deductibles, copays and other information through these documents.
- Phone: Call the number on your health card. Be sure to get a reference (tracking) number for the call.
Because you bear a greater cost burden for your health care costs, digging into this information is imperative to knowing the difference between a preventable patient balance and one you actually owe, before the bill arrives.