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There is a book I recently purchased called "Never Pay The First Bill". It covers this exact kind of scenario and tells you what to do step by step, all the way
by rthomas6 3y ago
There is a book I recently purchased called "Never Pay The First Bill". It covers this exact kind of scenario and tells you what to do step by step, all the way up to small claims court, though you usually don't need to go that far. Highly recommended.
More than likely you're going to need to get an itemized bill from the hospital listing the actual icd-10 charge codes and amounts for each service. Then you will need to cross reference this with your insurance's Explanation of Benefits document, which shows what the insurer paid for each code and the remaining that you owe. If there are any codes missing, there has been a miscommunication between the hospital and insurance, and the insurance was not billed for something. It is also possible there will be errors in the codes themselves, charging you for things you did not receive or received less than they said (charge code for 1 hr complex appointment when your appointment was 10 minutes). In this case, you will need to request your medical records, and cross reference them with the charge codes to dispute the wrong codes.
It also tells you how to deal with collection agencies.
- SoftTalker 3y agoI have not run into the problem of insurance denying charges for things they are supposed to cover, but I have tried (years ago) to cross-reference my medical bills with my EoBs and gave up as nothing ever really matched up.
- rthomas6 3y agoIt is supposed to. It is supposed to be the exact same codes. If that is not the case then you were mis-billed, which according to that book is a common occurance.
- benlivengood 3y agoYou need to request the HCFA (maybe this has finally gone away after ~10 years) or CMS-1500 claim form for outpatient (like a clinic or same-day surgery or medical imaging) or UB-04 claim form for inpatient (hospital/skilled nursing stay) service. The actual claims are generated and sent electronically as 837 or 837P formatted garbage (just look up the standard) by all but the tiniest providers but virtually any billing software can generate the equivalent "paper" form. EoB quality depends on your insurance carrier; if they don't provide a breakdown with the original charge codes and diagnosis codes and a coverage decision then complain and request a more detailed explanation. The most confusing part is the adjustments; every year the insurance companies and service providers in the U.S. waste a horrific amount of time and effort negotiating adjustment (discount) rates per insurance carrier (insurance always pays less than face value) and charge code. The provider picks prices that give them an overall net positive revenue given the set of adjustments from their (predicted) patient population and corresponding insurance carrier spread, so none of the prices or adjustments actually make any marketplace sense. If you end up having to fully pay a bill that insurance won't cover, try to offer the provider ~50% and they'll be pretty happy to write off the difference since they wouldn't get much more from insurance. There are also often payment plans and other assistance available if you ask the billers.
- SoftTalker 3y agoI mean, I'll get a bill from my doctor (actually his group practice or whatever) it will list services that I recognize, show what the insurance paid, and what I owe (if anything). It usually looks about right and I have just not ever found that the time needed to audit that against the EoB statements has ever been worth it. The times I tried I got a headache and gave up but like I said it was years ago, well before ACA or any possible reforms that might have been made in the area of transparency in health care/insurance billing reports.