Managing Medical Bills and Insurance Payments

Examining medical bills and insurance company explanation of benefits (EOB) can be confusing but doing so carefully can save you money. Whether you are on Medicare or still have private insurance, the steps are basically the same. This article uses the term “insurance company” to refer to both private insurance and Medicare where there is no significant difference.

First, unless it is an emergency, you should take time to learn whether medical services you need are covered by your insurance. Usually a simple phone call to the doctor’s office or your insurance company will provide this information. Medicare’s website, www.medicare.gov, is also very helpful. It is important to know if your medical provider participates in your insurance plan, since this will affect how much you will owe.

After you have received your medical services, follow these steps before paying a medical bill: 1) wait for the EOB from the insurance company; 2) wait for the actual bill from the medical provider; 3) compare the patient responsibility amount on the EOB with the bill; and 4) if the amounts are the same and if you believe that amount is correct, go ahead and pay the bill. This process is important because each insurance company and the medical providers who participate with that company’s plan have agreed how much the provider will be paid by the insurance company and by you for certain services. You cannot be charged more by a participating provider.

If the amount due shown on the EOB is different than the bill and assuming the provider participates with your insurance plan, then follow these steps. Initially, contact the medical provider and ask why. Often they will correct the bill. Then, if the provider refuses to correct the bill, contact your insurance company and explain the problem. Finally, if the insurance company confirms its EOB, pay the provider the amount due on the EOB. Ask your insurance company to notify the provider in writing of its decision. It is then up to the provider to work this out with the insurance company. Following what your insurance company states, at this level, affords you the best protection against improper medical billing.

Remember, however, if you receive services from non-participating or out-of-network providers, they do not have to accept what the insurance company pays and are not limited in how much they can charge you.

If you disagree with the amount due on the EOB or if the claim has been denied completely, you have the right to appeal. Contact your insurance company and ask a representative to explain the denial. Many times the provider or insurance company has made a mistake. If this does not solve the issue, contact your provider and discuss the information and ask for assistance. For example, there may have been a coding error, or the provider may be able to supply additional information to help get the claim paid.

If you are still dissatisfied, you may file an appeal with your insurance company. You can do this yourself, but you need to consult your insurance information about where to file and the time deadline. You should act promptly, since you may have only 30 days to appeal an insurer’s denial for services already received with a private insurer. The time period is longer with Medicare. It is very important, however, that you obtain documentation from your doctor about your condition and the services you received to submit with your appeal.

Guidance for filing appeals yourself with a private insurer can be found at www.PAHealthOptions.com. This information and guaranteed appeal rights with private insurance are provided as a result of the Affordable Care Act (Obamacare). Medicare patients can find this information on Medicare’s website.

Additionally, you should be aware that appeal rights extend through several levels, starting with internal appeals and then external appeals. Research indicates that appeals are often worthwhile. According to a March 2011 Government Accountability Office report, appeals filed with private insurers in Maryland showed that 50 percent of internal appeals and 54 percent of external appeals resulted in changed decisions in favor of the patient. Other states’ rates varied, but success rates were significant. Pennsylvania was not part of the study, however.