Every once in a while I will receive a letter from a disgruntled patient. It is usually regarding the financial aspects of their care and not a clinical problem. In most cases the patient is upset about a bill that we sent them. I can relate. I do not like getting bills either.
My office policy requires that all patient insurance be verified. This is to make sure the insurance has not expired or changed (a number of companies change insurance plans on their employees without giving, what I would consider, adequate notification). My office staff confirms insurance coverage over the phone or via the internet.
After a patient's active coverage has been confirmed, we ask some specifics about what procedures are covered. We also ask the insurance company what percentage of the surgical fees they will pay. This is where the problem arises!
When we get all this information we calculate what part of the surgical fees will be covered by the insurance company. We then collect the remaining amount from the patient before the surgery takes place.
An example...
Say a patient needs a $100.00 procedure X. The patient says they have insurance but not sure what kind.
We call the insurance company (information taken from the patient's insurance card). The insurance company confirms that the patient does have coverage with their company.
My office staff then explains the procedure and asks if it is covered, what percentage will they (insurance company) pay and what amount will the patient be responsible for paying?
Lets say the procedure (procedure X) is covered. The insurance company tells us that they will pay 80% of the fee and the patient will be responsible for 20%.
Simple math tells us that the insurance company will pay $80 and the patient will pay $20. This will cover the total fee of $100. We inform the patient that their insurance company has given us an ESTIMATE of how much they will pay (remember the insurance company has told us they will pay $80) and we ask them to pay their portion ($20) before having their surgery. They agree.
I perform their surgery. Everything goes well. Afterwords we, as a courtesy to our patients, submit a claim to their insurance company. All is good. At least that is what we think!
We submit the claim. When we get the check from the insurance company, they only pay $50 on the $100 surgery fee. What? Why did they only pay this amount and not the $80 they told us on the phone (or internet)? Again herein lies the problem!
We take the $50 insurance payment and add the $20 the patient paid on the day of surgery. A total of $70. That means that a balance of $30 remains on the patient's account for the $100 surgery. What happens next?
Well, the insurance company says they are not going to pay any thing additional. We then bill the patient for $30. Here is where it gets interesting.
The patient gets a bill from my office. They get upset because they think we have made a mistake, added extra charges or did not file their insurance correctly. The fact of the matter is their insurance company gave us bad information or just refused to pay what they said they would pay. Everything was based on what the insurance company told us they would pay.
Now, I am not saying we are perfect in my office and do not make mistakes. If we make a mistake we will do everything in our power to correct it. The problem is when the insurance company will not do the same.
So here we sit. We provided a good surgical service and the patient did well. The patient paid, or a least thought they paid, their portion of the surgical fee and the insurance company balked on their end of the deal. Not fair, right! I agree.
The only option is to have the patient pay the difference. This is very hard to explain to them. They thought they had paid all they were expected to pay the day of surgery.
Most people understand this concept and pay without too many questions. They get a report from their insurance company and understand that they will be responsible for what the insurance company did not cover.
However, some patients write me nasty letters and refuse to pay. They blame us and put no responsibility on their insurance companies. This is when it gets difficult. Try as we may, they refuse to pay and we ultimately have to turn their accounts over to collections.
Ok... why rant about this topic you may ask? I got one of those "nastygrams (my term for a nasty letter)" this past Friday. I thought posting this might be educational to our patients and therapeutic for me, nothing more.
Oh yeah, what happens if the insurance company makes a mistake and they actually pay more than what they say? I give the patient a refund within 30 days of receiving the insurance check! No problem.
I guess the morals of this longwinded story are:
1) Never completely trust what your insurance company tells you or your medical provider. They are in business to make money and not at all worried about your well being.
2) Get involved with your insurance claim (call your insurance company and ask questions if you are not pleased).
3) Learn how to read reports from your insurance company (known as Estimate of Benefits [EOB]) to make sure of what you might have to pay or to see if you may be due a refund.
4) Do not ignore your medical provider if they bill you. If you communicate with them they will more than likely work out a payment plan or other arrangements to assist you in paying down your bill.
5) Ask questions about your medical provider's financial policy in the beginning. It will open the communication lines and prevent you from being "blindsided" by a bill in the future.
That is all for now.
Regards,
Dr. K
