Insurance policies are purchased to protect our pocketbooks and life savings from unexpected occurrences or incidences that is for the most part, out of our control. Every month the average household is shelling out hundreds of dollars in premiums to protect against the “what if” damages for unforeseen losses that could occur to our homes, cars and lives.
If you are fortunate enough to have health insurance benefits to help pay for medical care when you visit a health care provider or facility, consider yourself very lucky. Health insurance premiums continue to rise by double digits every year making health insurance policies unaffordable and; therefore,unattainable by millions of Americans. And even if you possess the coveted health insurance card in your wallet, you have probably noticed that you are still forking over more of your hard-earned dollars for co-payments and costs to supplement what the insurance does not pay for.
Here’s how the claims process works…
Every time you visit a doctor’s office whether it be for preventive care or illness, five digit numeric codes are assigned to every single service you receive from the moment you are greeted by the health care personnel. There are approximately 7,800 codes which are published and updated every year by the American Medical Association in the Current Procedural Terminology (CPT) books.
And to complicate matters even more, another set of 3-5 digit codes are assigned to represent the disease, symptom or condition that your doctor finds wrong with you. Also known as (ICD-9/10) International Classification of Diseases and Related Health Problems. The 15,000 plus codes are developed and monitored by the World Health Organization.
These codes are a foreign language to most individuals not working in the health care arena and not easily translatable. It’s like a secret code used by health care personnel and facilities to communicate with insurance companies. It is their secret way to make it difficult for the average consumer to decipher if everything that is billed and adjudicated is on the up and up.
And you thought it was just the IRS tax code that was difficult to crack.
Simply stated, your doctor’s office will input and transmit all of these codes along with your insurance identification number via the internet to your insurance company.
Once this data arrives electronically at the insurance company, there’s no telling what will happen next. Many “clean” claims will automatically process (pay or deny) without the intervention of a human being based on your contract benefits in force and the time your services were rendered. Other claims will warrant manual adjudication if a red flag warning is attached to the any combination of the codes that were transmitted by your medical provider.
Some time after all that top-secret code communication between your provider and insurance company, you will receive a statement from your insurance company and doctor’s office outlining all of your expenses, insurance payments and bottom line- how much you owe.
Here’s the tip of the day::
Never ever, ever, ever trust what appears on those explanation of bullsheets. You must get out your Sherlock Holmes cap and magnifying glass to examine and compare every line item that appears on your statements. It doesn’t stop there. I recommend having a current copy of your health insurance contract handy and I don’t mean the two page benefit overview.
Just yesterday, my husband and I discovered that his insurance company was adjudicating all of his weekly claims incorrectly. It took me awhile to figure out what the problem was, but in the nutshell, they were applying a $40 co-payment to all his office visits when it should have been $20. His co-payments vary based on the type of service performed not solely on if the service is rendered by a specialist or primary care doctor. I had to dig into the guts of the contract to get this answer.
And $20 X how many weeks adds up fast. I called his insurance company this morning to have all his claims reprocessed. Why does it have to be so difficult for the consumer? If being sick and undergoing treatment is not hard enough for patients, why add the financial stress to the equation.
Health care and health insurance is nothing like it was years ago. You went to the doctor’s office and your insurance company paid just about everything.
I understand it is difficult to understand all of this mumbo jumbo. However, I feel it is important to shout it out and alert others that mistakes happen that are not always obvious at first sight. I know, sometimes it is just easier to pay the balance due rather than fight with billing professionals and insurance company.
Trust me on this one, take the time and sort through the bullsheets. You will be surprised on the mistakes you find. Lastly, don’t be afraid to ask questions or question the so-called billing authorities. Just remember, the customer is always right!
Please feel free and share your thoughts in the comments section.
Thank you for tuning in and reading my blog. I appreciate all of you who take the time out of your day to check in. Have a wonderful weekend and I will see you on Monday.