copay

Medical Bills – Part 2

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I went to the emergency room on November 15, 2021. I resolved a bill from that day on June 30, 2023.

The provider submitted a claim to my insurance company immediately after my stay there. The submitted charges were $1526. My insurance adjusted the amount, paid about $1100, and said I was responsible for about $60. My explanation of benefits (EOB) even included a copy of the check they submitted to the provider, which is not typical. The check was date December 21, 2021.

The provider submitted a second claim, exactly the same as the first one, to my insurance company in December 2021. My insurance denied the claim because it was a duplicate. Simple enough.

The provider only received the denial, and not the check nor first EOB.

I received a bill from the provider in March 2022 for $1526. That didn’t make sense. I knew my insurance should cover most of a claim. I looked through my insurance coverage and confirmed I would only owe my co-insurance since our deductible had been long met. I reviewed my EOBs and noted the duplicate submission, so I called the provider. I told her the story, but she kept talking over me and not hearing that the denial was because it had first been paid. She said she was going to call my insurance company. I filed the paperwork and assumed it would get handled or that I’d receive another statement prompting me to take action.

In August 2022, I received a letter from a collections agency. I was pretty mad. Not only did I not receive information from this woman who had a job to do, they never sent another invoice/statement/bill to me.

On September 1, 2022, I called the collections agency as the letter told me to, plus I wanted a record that I had acknowledged the collections notice. The collections company told me to detach the part of my letter that had my information and mail it back to them asking for details. I did that immediately. I later received a letter that said “physician says you owe $1526 for services rendered on 11/15/21.” Thanks; that’s useless.

The same day that I called the collections agency, I called the provider. The man I spoke to told me he took my account out of collections status and would look into it. He told me to send an email to them with the EOBs and an explanation of what happened, which I did immediately that day.

On October 13, 2022, I hadn’t heard anything. I had sent two more emails since that time, trying to avoid a phone call, but at this point I had to call. I figured at any given moment, these people would just send my account to collections instead of put any effort in. The person I spoke to this time said they’d escalate this to the posting team for review, and they’d need 45-60 days to research it.

Nothing.

In December I called again. I asked for a supervisor immediately to avoid having to explain the story once again, but they made me explain it again. I got through to a supervisor who finally understood the story that there is a check out there for them. She said she sees that the issue is that the PO Box was wrong for where it was sent. She said she would contact my insurance about it. She emailed me the next day to say she tried 3 times to get to my insurance and couldn’t. That’s complete bull. I’ve never not been able to reach someone at my insurance agency via their 800 number.

I responded to her email 3 times asking for an update through December and January. At the beginning of February, I finally called again. This time, I called my insurance company and asked them what can be done. She called the provider via a 3-way call. The man said they’d resolve it and he escalated it. Same. Old. Story.

I gave them another 60 days and called them in April. Nothing different. This supervisor told me that she could see it being worked on and moving through the system. She said she really needed to allow it to work through the system and to give another 60 days.

I called on June 29, 2023. I was able to get through to the same supervisor as the April call. She kept me on hold a majority of the time. After a half hour, she came back and said “I’ve escalated this to the posting team. I appreciate your patience, but I really need to give them another 60 days.” No. Unacceptable. I’ve wasted hours of my life trying to get this resolved, and it’s not even my problem to resolve. It has only become my problem because they sent me to collections. I told her to send me to someone higher than her, and I was done being thanked for my patience.

A new person got on the phone. I said the only acceptable outcomes at this point are 1) you wipe the slate clean and call it a wash because you’ve had more than enough time to ‘find’ the payment from my insurance company, or 2) you call my insurance company and get them to stop payment on the previous check and reissue payment somehow. She said she’d look into it with the posting team. I said “clearly, the posting team doesn’t know how to do their job, and I’m tired of being told for an entire year now that we’re waiting on them to find the payment.” She agreed.

She looked at some screen and something clicked. She said that the payment was processed through a third party, so they take a cut of the check from the insurance. All this time, they’ve been looking for $1100, but they should be looking for something less than that. She called the company that processed the payment, found out the amount they sent to the provider, found the payment amount in suspense, and applied it to my account.

That left a balance of $60 owed from me, and she graciously zeroed that out for my troubles. I didn’t have a problem paying $60, but I did have a problem with their way of handling this issue.

I had heard from someone two other times that sounded like they were actually going to help me. I had no faith that this was the end of the road when I hung up the phone on 6/29. I started to look for alternative courses.

I submitted a claim to the Better Business Bureau. They accepted my complaint within a few hours, but I ended up calling to withdraw the complaint on the following morning since this woman fixed my issue finally.

I called the Federal No Surprises Help Desk. Truly, I didn’t think this counted because it wasn’t “surprise billing.” However, they have a system that asks you questions and gives you a course of action. In my case, they said to call and start a claim. Unfortunately, I did call, and she said that since the date of service is before the No Surprises Act was established, she couldn’t help me.

She suggested I call a number in Kentucky for my issue. I called and left a voicemail, but that felt weird. I looked up some options specific to my state, and there was a way to file a complaint with the Attorney General. I submitted that complaint, which I need to figure out how to withdraw now.

I’m skeptical that this is over. The lady I spoke with said she will send me a zeroed out statement in the mail, so I’ll be holding my breath until that actually shows up.

There are so many times where I, as a consumer, am just stuck. I don’t understand. The consumer has no help or protections that are easy to find or take advantage of. I just have to keep calling this company and hope that eventually they resolve it. Yet they could send me to collections and completely ding my credit worthiness, even though this was their issue and fault.

Nineteen and a half months after my date of service, I may actually have this resolved. This was a bill for $1526. A lot of people don’t have that kind of money to erroneously hand out. I hope that someone reads this and thinks before they pay their next medical bill to ensure that it’s accurate and truly the amount that’s owed.

Medical Bills

mrsonedollarallowanceLeave a comment

Here’s something different. Medical insurance isn’t something I’m going to pretend I understand fully, but I know enough to protect my money. So here’s two quick stories about how due diligence saved us hundreds.

First, an overview.

When you see a provider (e.g., doctor), they bill your insurance on your behalf. The claim that’s submitted is reviewed by the insurance’s benefits administrator, and any coverage is paid out. Your insurance will likely have a “disallowed” amount (what your insurance deems is too expensive to be billed for the given service), a benefits paid amount (what insurance pays on your behalf), and then a member responsibility amount (what you owe). Once the claim is processed, these are outlined in an explanation of benefits, or an EOB. If and when you receive a bill from the provider, verify against your EOB to ensure that it aligns with your insurance benefits.

Here’s an example of an EOB. By using a provider that is in-network (in a negotiated agreement plan with my insurance company), the doctor and the insurance have agreed costs for services provided. My insurance’s “allowances” are negotiated with each provider who participates in the network. Allowances may be based on a standard reduction or on a negotiated fee schedule. For these allowances, the provider has agreed to accept the negotiated reduction and you are not responsible for this discounted amount. In these instances, the benefit paid plus your coinsurance equals payment in full. So here, for the services that I received, the insurance company is saying, “I see you billed for $115, but we agreed that this service only costs $65.34, so that’s what we’re allowing.” You, as a covered member, are not charged for the ‘disallow’ amount of $49.66.

In our case, we have a high deductible plan, which means we have to spend a certain amount of money on covered services before the insurance pays out benefits. Ours is $3,000. This means that for the first $3,000 worth of doctors visits to in-network providers, we’re paying the total allowed amount (e.g., our son had to go to the ER, and we paid $609 for the visit, which is the fully allowed amount). There are plans out there where you don’t have a deductible, but you have a copay (e.g., I had a plan where I paid a flat $20 for each doctor’s office visit and $125 for each hospital visit, but I was also paying a higher premium for that coverage type). In a future post, I will share how we compared our plan options and chose a high deductible plan.

After we meet the deductible, most of our services are covered at 95% (i.e., we’re responsible for paying 5% of the allowed charges). In the example above, we had to pay 5% of the $65.34, or $3.27.

There are tons of nuances to insurance though, but hopefully this broad overview helps understand how to read the EOB. I have more stories of where my interpretation of the coverage in my brochure doesn’t seem to match the benefits administered, but those are for another time. For now, here’s how we protected hundreds of dollars by staying on top of our coverage.

MR. ODA’S STORY

Speaking of nuances, here’s one of those. Preventative care is covered at 100% (e.g., maternity screenings and annual physical exams). Mr. ODA needed a physical to qualify for his agency’s wellness program (they’re given 3 hours per week to exercise). When he went to get the physical, it got coded as a sports physical because the doctor had to sign off on a paper that said he was healthy enough to participate in the wellness program. A routine annual physical is fully covered by insurance, regardless of deductible. Apparently, a sports physical is not the same concept and regular coverage requirements apply.

Mr. ODA had to call back to explain that the exam was routine with a signature on paper, and not any more in depth to be considered a sports physical. The doctors office offered a reduction in the amount owed, twice, but eventually realized they were spending more in postage and phone calls than the bill was worth while Mr. ODA fought the coding, and they wrote it off.

MRS. ODA’S STORY

I saw a doctor in December 2019 when having pregnancy complications. In February 2020, I received a bill, which I promptly, and erroneously, paid. A few days ago, I received a check for the amount I paid a year and a half ago. So it wasn’t a quick resolution, but I wasn’t going to let $300 go.

The bill said:
Charges to Date: $451.00
Payments/Discounts to Date: $157.85
Remaining Patient Balance: $293.15

I had seen multiple doctors in a short period of time, so I was just in auto mode to pay all the medical bills that I had. After I paid it, I realized that on the back of the bill there were more details about that “payments/discounts” line item. There were three columns: Insurance Payments, Patient Payments, and Adjustments to Date. The total $157.85 was in the Adjustments to Date column, and the insurance column said $0. I checked into my insurance claims online and didn’t see this date of service. Well, I’m insured, so this should have been submitted to my insurance for review first. I called the hospital to indicate that there was an error made, and I shouldn’t have paid this in full, even with an “uninsured discount” they graciously offered me.

I called the hospital to ask why this wasn’t submitted to my insurance and discovered that my name was spelled wrong, my insurance was entered wrong, and this claim wasn’t tied to all my other hospital-related claims I had processed. Supposedly, they updated my information and resubmitted. I still didn’t see it on my online claim history after the 30-45 day window they told me, so I called again in April 2020. I was told they would resubmit. Two months later, I was managing a newborn and we were just deciding to move, so this fell off my radar. Then all of our things were in storage for two months. By the time I got this paperwork back out, it was March 2021.

I explained my story to the hospital again and asked for it to be properly submitted. I was again told they would submit the claim, but this time they’d submit by paper handling. Again, nothing showed up in my insurance. I called in April 2021 and was again told that they would try submitting again. This time I escalated to a supervisor. I said that this was unacceptable, and I didn’t want to keep being told they would try again, delaying my reimbursement by another 30-45 days each time I called. The supervisor said she would ensure the paper claim was sent out and call me back in a week. I never got the call. On May 18, I called again, immediately asking for a supervisor. This supervisor said that my account showed a refund was approved, but he needed to issue it (why couldn’t that just have been done?!).

Well, on June 1, I received a check in the mail for $293.15. That’s the amount I paid back in February 2020 for a December 2019 date of service. I could have written this off in my mind a year ago and not made these five or six phone calls, taking about 90 minutes of my time in total. I could have said to myself, “I called. There’s nothing more I can do.” But we wouldn’t be in the position we’re in now with our finances if I kept saying “oh well, that’s all I can do.”

The moral of the story is that you should be an informed consumer. If you know how to determine your benefits and calculate your coverage, you can make sure the proper payments are made to the provider, and that you aren’t overcharged.