An Open Letter to Patients About Medical Billing

June 4, 2016
P.J. Cloud-Moulds

Patients can understand so little about their health plan that the billing department is automatically blamed when something goes wrong.

As a follow-up to my latest article, "Educating Patients on Healthcare Benefits," I want to shift gears a bit and share my perspective as a billing manager and consultant on where the billing department's responsibilities should lie. Here are scenarios where it isnot the billing department's fault or responsibility if something goes wrong during the revenue cycle:

• Coordination of benefits: If you don't tell us about your other insurance plans, we can't bill them. If you do not call your plan and let them know who is primary and who is secondary, both will pay as primary - and then we are left with a mess to clean up.

• If you have a deductible or coinsurance that the front office will be collecting, they collect based upon how the provider codes. If they collect incorrectly, it is not billing's fault. Don't blame us.

• When your insurance plan quotes us benefits, and we collect according to their instructions, don't get mad at the billing department if we process your claim differently. Call your insurance company and yell at them.

• Your plan may have some exclusions on specific benefits or body parts. If those exclusions are not provided at the time of verification, that's on your insurance plan for not divulging that information. When we bill you for the services rendered, do not yell at us, call your insurance company and ask if they would reconsider paying the claim. If not, it's up to you to pay the provider.

• When you purchased your insurance plan, it's up to you, the consumer, to review the plan benefits. It would be like buying a car without knowing if it had power steering, air conditioning, or a stereo. You need to review all of the details of your plan - if you don't understand it, call your insurance company and have an educated representative go over it with you.

• If the provider is out of network with your plan, there is most likely a reason. It's probably because of poor reimbursement from your plan.  On rare occasions, a similar provider in your area is already on that plan, and the insurance company feels that is adequate in serving their customers. It's not because the provider did something wrong and is not worthy of being in your plan's network.

• Don't blame your billing department if the plan has assessed a cost share to you. This could be in the form of a copay, coinsurance, or deductible. Welcome to healthcare, it's expensive.

• When you are receiving care under a workers' compensation claim and the provider has to wait and obtain authorization. Call your adjuster and get them moving, neither the provider nor billing department is responsible for moving this along.

• Don't blame us if you feel our charges are too high. The amount paid by your insurance company for medical services in the same geographic area is based on what providers in the area usually charge for the same or similar medical service. That "usual, customary, and reasonable" charge (UCR) sometimes is used to determine the allowed amount. Look it up on Healthcare.gov.

• If authorization or precertification is not obtained. This is the front- or back-office staff's responsibility. If the billing department is not informed of needed information, the claim will go out without it. Call the providers office and talk to them about obtaining a retro-authorization for the visit.

These are scenarios where it is the billing department's fault or responsibility is something goes wrong during the revenue cycle:

• If any identifying information is incorrect on the claim (patient name as it appears on the insurance card, date of birth, policy or group number, subscriber information, etc.) Most all billing departments have a "scrubbing area" in the revenue cycle. This is where these errors are identified and fixed prior to the claim being submitted to the payer.

• When an insurance company requests chart notes or a prescription from the visit. The billing department will submit those when it is requested on a delayed EOB (explanation of benefits). This does not mean we are not doing our job when we have to resubmit the claim with this required information. Oftentimes, we are unaware of this requirement up front.

So, if you are a patient, and something looks wrong with your medical bill, feel free to call the billing department for direction on who to call with your questions. Please, remember also, that the people answering the phone are just like you and me. We are people. Don't start the conversation by yelling - that won't help you get better service, trust me.