MANAGING YOUR MEDICAL BILLS & INSURANCE PAPERWORK: TIPS FOR MAXIMIZING REIMBURSEMENT
BY HARVEY J. MATOREN, MPH, CCAP
Do you become frustrated and overwhelmed when managing your medical bills and filing your health insurance claims? You’re not alone. It can be extremely difficult for the average patient or caregiver to get through the “maze of insurance land.” For people with a chronic or terminal illness, or acute episodes of illness as well, managing and filing insurance claims can be a particularly complex, frustrating, stressful, confusing and time-consuming process. But, given the high cost of healthcare today, it is critical that claims be filed and managed correctly to ensure you receive all the payments due to you, to make certain that you pay only the bills you’re supposed to pay.
There are several ways to minimize the difficulty that surrounds the process of medical bill management and claims filing. Carefully following the suggestions here can be of significant assistance.
To protect yourself and to help maximize reimbursement, you might want to use a professional medical bill management and claims filing service. If you do file and manage your medical bills on your own, you can learn to avoid many of the mistakes that are so easy to make. Even if your provider files your claims, you need to be in control in managing the process regarding reimbursement and paying bills.
Here are some helpful hints to get you through the red tape, lower the stress level and, hopefully, put more money back in your pocket.
1. Whenever possible, try to have the doctor’s office file your claims and even accept assignment.
If your doctor accepts assignment, it means that he agrees to file the claim and to accept, as payment in full, the amount the insurance company approves. Your doctor cannot balance bill you for the difference between his charge and the approved amount. In most cases, the insurance company will pay the provider directly when he participates with the insurance program. If the provider accepts assignment or participates with your insurance program, your only obligation usually is the co-payment, as stated in the policy. Many providers will ask for this co-pay at the time of your visit. Try to have them bill you for the co-pay after they have filed the claim and been paid by the insurance company. Many people pay the wrong co-pay. For example, they pay 20% of the charged amount instead of 20% of the approved amount, and consequently overpay and never get back a refund.
2. If you have more than one insurance policy, do not assume that the provider will file the claim.
If you have to file the claim, be certain to give the insurance company all the information it needs. Incorrect or missing information will only cause a delay in processing the claim. If you need to submit an itemized statement, be certain the following information is included:
• Description of service
• Charge for each service
• Date of each service
• Location of each service
• Name of the provider (doctor, hospital) who actually treated you
• All appropriate insurance numbers
3. File your claims as soon as possible.
Don’t let the bills or receipts pile up – and, certainly, don’t save all your claims until the end of the year. Many people think it’s easier to file their claims one at a time.
4. Don’t pay any bill unless it is clearly understood that it is a final accounting and you are responsible for it.
Never pay a bill until you have received the explanation of benefits form from your insurance company, which indicates who and how much was paid. Bills are sent prematurely, and many patients pay bills before knowing if the doctor or hospital has received a payment from the insurance company. Duplicate payments to the provider very often result in refunds that are due to the patient but not returned. When you do pay a bill, keep records according to the date of payment and check number. This is necessary if you receive a duplicate bill indicating that payment has not been received, and verification of payment is required.
5. A lack of knowledge regarding benefits very often leads to patients being billed and paying for services that should be reimbursed or written off.
Claims are rejected for what the insurance company says are non-covered services. Check your policy to be certain of the covered benefits.
6. Appeal rejected claims regardless of the reason given.
In addition, appeal all claims that you believe were not paid at the appropriate level. An insurance company may say that the provider’s charge exceeds the allowed amount (referred to as exceeding the “usual and customary charge”), but this may not be the case. A Government Accounting Office (GAO) study several years ago indicated that, of the millions of dollars of rejected Medicare claims annually, only about 2% are ever appealed. However, of those 2% that are appealed, approximately 75% are overturned in favor of the patient!
7. If you have to file your own claims, make copies of everything you submit.
This will make it easier for tracking and follow-up. It will also facilitate resubmitting claims if and when the insurance company tells you they never received the information.
8. Timely submission of claims is critical in receiving reimbursement.
Even if your provider agrees to file the claim, you should be sure that it is filed within the filing time limits imposed by the insurance company. Claims filed too late could result in a bill to you from your provider for services that should have been paid by insurance.
Above all, don’t be intimidated by the system. If you are persistent, aggressive and assertive, you will be able to maximize your reimbursement, minimize your stress and get peace of mind.
ABOUT THE AUTHOR:
Harvey J. Matoren, MPH, CCAP, is President and co-owner of Health Claims of Jacksonville, Inc. and Claims Security of America. He has over 45 years of experience in health care management and the health insurance industry. Prior to starting Health Claims of Jacksonville in 1989, with his wife Carol, he was Senior Vice President of Florida’s largest health insurance company, Blue Cross and Blue Shield of Florida. Upon leaving Blue Cross and Blue Shield in 1989 to start-up Claims Security of America, the statewide HMO had 250,000 enrollees and 500+ employees. He has a Bachelor of Science degree in Psychology from the City University of New York, a Master’s degree in Public Health from UCLA, has completed all course work for his doctorate at Columbia University and completed an advanced management program at the Harvard Business School. He is licensed and bonded as a Public Health Adjuster by the Florida Department of Insurance. Email firstname.lastname@example.org or browse the website at