1. How should I file the statements, invoices, and explanations of benefits forms?
It is important that you open up every single envelope, because you could end up throwing away a reimbursement check! You can sort the documents you will receive in three ways:
(i) By medical provider (for example, doctor's name, hospital name, or lab name);
(ii) By date of the first medical procedure or service on the document (since many documents itemize services from several dates grouped together on the same form); or
(iii) By type of document (for example, all invoices from medical providers, all explanations of benefits forms from your first insurance company, all explanations of benefits forms from your second insurance company).
Any of these systems will work. What is important is to be consistent in the filing method you use and to keep it constantly up to date. If you keep track of all your medical billing information, you will know when and how much to pay.
2. What documents will I receive if I have medical insurance?
If you have a private insurance plan (Blue Cross, Blue Shield, etc.), or if you have Medicare with a supplemental insurance plan, there are three types of documents you will probably receive. They are:
(i) The initial statement or invoice (this may or may not be sent out);
(ii) The Explanation of Benefits; and
(iii) The final bill.
3. What does it mean when the document says, "This is not a bill"?
The first document you may receive in the mail is an initial statement or invoice from your medical provider. Not all offices generate and send this form. But, if your doctor or hospital does, this invoice will usually say "This is not a bill," and it itemizes all of the services you received.
Unless you are a "private pay" patient who is responsible for all of your medical bills, you will probably not have to pay that entire total you see at the bottom of the bill. This form is simply telling you how much is being billed to your insurance company.
4. What is an "EOB"?
After the claim is processed, you will receive a second type of document called an Explanation of Benefits (EOB). If your primary insurance company is Medicare, you will receive a form entitled "Medicare Summary Notice" that itemizes which services they have processed. Medicare or the insurance company will either authorize payment or deny it; this statement will tell you how much of the bill was approved for payment and who was paid.
5. If my claim is denied, what do I do now?
If you see that the claim is denied, call the biller at the office to see what caused the denial. It could be something as simple as a wrong code. Ask that the claim be re-submitted. Most offices will do this automatically, but it does not hurt to call to follow up.
6. I think I need a chart to keep track of all of these claims. What kind of information do I need to record?
After the claim is paid, you will note:
(i) How much was "approved";
(ii) How much was paid;
(iii) The date it was processed;
(iv) If the payment was to you or to the provider; and
(v) If the provider "accepted assignment" of the claim.
7. Do I cash the reimbursement check or send it to the doctor?
If there is a check issued to you, deposit the check, then pay the medical provider the same amount you were reimbursed. Make a photocopy of the check for your records.
8. What if I have a second insurance policy?
If you have a second insurance, the medical provider's biller will submit a claim to that second insurance company after the first insurance's Explanation of Benefits form is issued. The second insurance company will also send you an Explanation of Benefits (EOB) for each item considered by the first insurance company.
When you receive an EOB from your second insurance, you need to record on your chart:
(i) How much was approved for payment;
(ii) The date it was processed;
(iii) How much was paid;
(iv) Whether the payment was to you or directly to the medical provide; and
(v) Whether you have a balance due for your out-of-pocket payment to the medical provider
If you have two insurance policies, then you will determine how much you will have in "out of pocket" expenses for that service, now that both insurances have processed the claim.
9. What is the "final bill"?
The third type of document you is the final bill, which you will receive after all insurances have processed your claim. It will show the amount of the original bill, each payment from insurance, any "write offs" or discounted balances and, finally, your balance due.
10. What if my "balance owing" does not match what is on the final bill?
If you receive a statement from the doctor's office showing a balance owing, and it does not match your records, call the biller to ask for an explanation. If you do not understand the terminology or jargon, keep asking until you have a satisfactory explanation. You may want to have a meeting with the biller so that you can present your paperwork and show how you arrived at the amount due.
11. Why do I need to track every health insurance claim?
If you keep track of all the medical billing documents, and what they mean, you can tell when your insurance company has paid, if you need to do any follow-up with the medical biller, and what balance may remain for you to pay.
Remember, if you use a recordkeeping system to keep track of your medical billing, you will be more likely to get all the benefits due to you from your insurance coverage. You need to know that you are not paying out-of-pocket for services that are covered by insurance.
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SmallTown Duo, owned by Sibyl Day and Mary Benson, specializes in medical and legal books for consumers. They publish a popular book called "What Did the Doctor Say? A Guide for Before, During, and After Your Hospitalization." The book covers topics such as questions to ask about your diagnosis, medications, doctor visits, and avoiding common medical errors. For more information, visit their website. http://www.SmalltownDuo.com
