Q&A: What If My Medical Bill Is Wrong?

A Q&A with Melissa Craig, benefits advocate for Kuzneski Insurance Group, who handles these sorts of situations for our clients. 

Question: When might a patient find themselves with a bill? 

Answer: This could be for several reasons. Maybe you went to an out-of-network provider and you're getting balance billed, it could be because the service that you went to wasn’t covered under your plan, or it could be because the insurance company only pays a certain percentage toward the service that you received. (Balance billing is the difference between the provider’s charge and the amount allowed by the insurer.) Or it could be that your new insurance plan didn't take effect before you went to the doctor or got a prescription filled. 

Question: What steps should I take to get my billing issue resolved? 

Answer: Reach out to your insurance broker. We're happy to help. Send over not only the bill, but the provider’s name, the date of service and an Explanation of Benefits (EOB) if you were given one. We want as much information as possible so we can go back to the provider and the insurance company to see why you’re left with a bill.  

Question: What do you do from there? 

Answer: We call the insurance company. We try to understand what services were provided based on the bill/EOB and why the insurance company didn’t pay the entire bill. Just like there are multiple reasons why a patient could be left with a bill, there are multiple reasons why an insurance company didn’t pay anything toward a service. Sometimes the provider can code a service incorrectly. When you look at a bill or an EOB, there is usually some type of code tied to the service that is being offered. If it isn’t coded correctly, the bill can bounce pack to the patient. Sometimes the provider’s office submits the bill to the wrong claims department. In this case, it’s just as easy as giving the provider the right claims address, and they can refile the claim the same day. In some instances, we have seen when our clients move from one carrier to a different carrier, the provider submits the claims under the patient's old insurance.  

Question: What’s next? 

Answer: We call the provider’s office. Based on what we understand from the insurance company, we’re able to negotiate and work with the provider’s office to see what went wrong. If it was a coding issue, we explain that they need to recode the service and resubmit the claim. If it’s because they submitted the claim to the wrong address, we educate the provider on where they should send the claims moving forward. Sometimes they can’t find the patient’s insurance information in their system, but we can give the patient’s member ID and information to them in real time. If the situation gets too complicated, we are able to loop in the insurance company with the providers so we can have another expert on the line to help resolve the issue.  

Throughout this process we are keeping the employee in the loop. Sometimes it can take a couple of days to get all of the information in order, but we want the employee to know that we’re still working on it for them.  

Depending on the information that we get from the insurance company and the provider, we are able to have the provider resubmit the claims and have the bill reprocessed so the employee is left with no bill. In other instances, the employee is responsible for the amount that is owed due to seeing a provider out-of-network or seeking a service that isn’t covered under their insurance plan.  

Question: So that’s it? 

Answer: Once we are finished with those steps, we educate the employee on what we found. We let them know the next steps (if there are any) and let them know that if they have any billing issues moving forward, they should reach out to us directly. 

Here's a real-life example of how Melissa helped one of our clients:

After our child was born, he was not picked up on our health insurance for several months due to a glitch on the insurance carrier’s side. We ended up with a $1,000-plus bill from a basic well visit. After spending hours on the phone with both our PCP and the insurance carrier, I reached out to Melissa Craig for help. She told me to send her everything and that she would take care of it. And that's EXACTLY how it went. Melissa and I got on the phone with both companies at the same time and discovered that the visit was never billed.  Melissa followed up with me every 3-5 days to keep me posted on the status of the issue. In the end, I received a $0 balance bill! 

This situation had my wife and I at the end of our rope. We felt like we were being robbed right in front of our face, and there was nothing we could do about it. Melissa's help came at a perfect time.  She was thorough and professional in her follow-up.  She went above and beyond to make sure we were constantly updated on the status of the situation.  You have an absolute superstar in Melissa -- hold on to her and she will make your business look amazing in the view of your clients.  I cannot thank her more for her help and persistence! 

-- JD Vidal, Diamond Kinetics 

You may also want to read: What If I Have a Claims Issue?