Top 5 Medical Billing Questions Answered: Your Bill Validation Guide

Navigating the mountain of medical correspondence and bills is one of the most stressful parts of receiving care. Melody Mulaik breaks down the top five most confusing medical billing issues and gives you a clear, actionable plan to validate every charge, so you only pay what you truly owe.

Learn the critical difference between the communication that says "This is not a bill" and the final statement that requests payment. Most importantly, Melody provides the one non-negotiable step you must take with your insurance company before making that payment.

Featured Topics:

• Validating Your Bill: The essential first step is to log in to your insurance company's website to review the Explanation of Benefits (EOB) and confirm your patient's responsibility before paying any medical bill.
• Handling Unsubmitted Claims: If you receive a bill but the claim isn't showing up on your insurance company's website, call the provider's billing office and ask them to resubmit the bill.
• The Timely Filing Rule: If you get a bill months after a procedure, check your EOB to see if the insurance company denied the claim due to the provider missing the "timely filing" deadline; if they did, you are not obligated to pay it.

In this episode, Melody discusses:

• [00:00] The stress of medical correspondence and why providers communicate with you.
• [01:06] What to do with the initial "This is not a bill" statement.
• [01:54] The non-negotiable step to take once you receive a bill—checking your insurance claim.
• [04:36] Action plan: What to do if your provider failed to submit the bill to your insurance.
• [07:11] Why do you receive multiple bills for a single ER visit?
• [10:43] The "Timely Filing" rule: Do you have to pay a bill received months later?.
• [13:08] Detailed breakdown: How to read your Explanation of Benefits (EOB) to find your exact responsibility.

Want to Ask Melody? Visit: https://melodymulaik.com/ASK Don’t forget to subscribe so you won’t miss an episode. If you've ever tried to get an urgent appointment with your doctor and were told they have no availability, this episode is a must-listen.

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Transcript

0:12

One of the things I think that causes a lot of stress for people and understandably so, is the amount of correspondence and not a bill. It's a bill information from hospitals, physicians, all these things that happen after you've had care, whether it's going to your physician's office again, you've had a hospital visit, you've been in the hospital. And all of a sudden, you're getting all this information and you're trying to figure out, what do I need to do with this? Do I pay this one? Do I not pay this one? How do I make that determination? Well. Several reasons that these organizations are communicating with you. One is they're basically sharing with you what they're doing as it relates to your visit or to the care that you've received. So I'm going to use these terms interchangeably.'Cause there again, there might be a hospital visit you have or hospital stay, or physician visit. Regardless, all these organizations are going to be billing an insurance company for the services that you received. So the first time when you get that correspondence, it says, this is not a bill. And you think, then, why are you sending this to me? This is visibility into what they're sending to your insurance company. So I would argue you still need to look at it. Because you need to look to say, what are they billing the insurance company for what I had. And hopefully, you look at it and you go, yep, that's true. I was there on that date. And that looks like the services that I received. And that may be the extent of what you need to do at that point. But if you look at it and you think, what is this? I wasn't there on that date, or I never had that particular services. It's really a heads up at that point. Doesn't mean you need to do anything with it, but just know this is what's gone to the insurance company for that. Once it switches from, this is not a bill to this is a bill. What that says is they've worked with your insurance company at that point. And the insurance company has hopefully paid them what they owe them or they've not paid them, but something's happened at that point with the insurance company. And they're now telling you, this is what you now owe us. Well, the first thing you need to do when you get that bill before you say, oh, this is what I owe. Let me write that check, or let me go online and make that payment, is you need to log into your account on your insurance company's website, and you need to say what they said about your particular bill. So, when you log into your insurance company and you go to claims, it will show you. This is who submitted information on your behalf'cause one of the things that you sign electronically nowadays, at every physician office, every hospital, there's a document that you sign that says, you give permission for them to bill on your behalf. That's why you're signing this. This is how they were able to bill your insurance company with it. But you want to go look at the claim and you want to look at that data service that matches what they submitted. You want to look at what did they bill on your behalf and you want to look at what they paid. Now, they're never going to pay exactly what was billed, and that's a whole another discussion, we'll have it another time. But you're going to look to say, okay, this is what they charged. This is what your insurance company allowed. In other words, that's what they'll say based on their contract with'em. Okay, they billed me a thousand dollars. The insurance company allowed 300 and they've paid. 80% of that, they paid$240, and so I now owe the remaining 20% of$60, and I validate. I go, yep, that looks right. I owe$60. I compare it with what that physician office just sent me that said I owe him$60. I feel good about that. I'm going to go pay my bill. But I'm looking for that validation that whatever that physician office said or whatever that hospital said, matches in the insurance company's website. If it doesn't match, there's a whole process that we need to go through to validate and determine where the issue is. But just as our very first big step, that's the big thing that we want to validate. And hopefully, the majority of the time you're going to see that when you go onto that website and whether you're looking at labs or you're looking at doctor's visits, all those other types of things that you're going to see that very quickly matches and that you can pay that bill that came in with confidence that things are being accurate. What do you do when you know that you had services performed by physician? You're at a hospital. You gave them your information, your insurance information. When you were checked in, you went through the process, but you get a bill from that organization and you go to your insurance company's website, but you don't see that they ever submitted it to the insurance company. You don't see it on the insurance company's website, which really translates into they didn't submit it to the insurance company. And you said, how did that happen? I gave'em the information. Well, I can tell you it happens a lot more times than you think. There's a lot of different reasons it's happened. The reasons don't matter for our purposes. What you need to know is if you go onto the insurance company's website and you log in and you've got a bill in your hand from your physician's office or your hospital and it's not matching, the first thing you want to do is pick up the phone and call that phone number that's on that bill and say, I see I have a bill here and it says that I owe you X, Y, Z, but I don't see on my insurance company's website where you submitted the bill to them. I need you to bill my insurance company with that. And their response should be, oh, let's verify the information that we have on file for you. So, when you call'em, make sure you have your insurance card in hand. Otherwise, you're going to have to stop a minute and go scramble and go get it. But have that insurance card in hand and talk to that particular person who answers the phone. It's going to be to somebody in that billing office and make sure they have that information. If they said we did bill them, you say, since it's not showing up on the insurance website. Could you please submit it again? That's a reasonable request and it's something that they should do. You may find that they need to resubmit it. You may find that they had it incorrectly entered into the system. You may find that they pulled over old information into the system for that. A lot of different ways that can happen. A lot of times I see it happen more in situations where maybe somebody has surgery. And when you have surgery, you know you're going to get an anesthesiologist bill. And you may get a radiologist bill and you may get other bills and those providers that are a few steps away from you that you don't directly see. Getting that billing information correctly over to them is sometimes where things break down. So, again, not uncommon at all for that anesthesia bill to not necessarily go to the right person with that. Again, talk to that person, whoever that phone number is on that bill, make sure they have that right information with that, and get them to resubmit it. When you do that, that basically adds another 30 days to the process. Generally, when we talk about anything around billing as it relates to things, if you're calling and giving them information, you're submitting a payment, all those things. They generally work in a 30 day billing cycle. So, if you get a bill two days later or even a week later. Don't stress about that because you just had the conversation a couple of days ago. I can promise you they're not working that fast to be able to get you an updated bill that quickly so that sometimes we get stressed because we get that bill and you think, I just talked to'em a week ago. Why is this still incorrect? It's still got to catch up, so give it some time. Give it that 30 days when that next bill comes 30 days later, that's the one that should be corrected at that point, and it should be accurate information. But again, go back always to your insurance company's website, validate that information, confirm that it's correct before you make that payment to your physician's office, to your hospital, et cetera. Jan, my neighbor had a question. She had to go to the emergency room. She's okay now. And she received a couple of different bills related to her visit and she was questioning, were these bills accurate? Am I going to get more bills? Why do I get more than one bill? And that's a really great question. And emergency room's a good example of where you've got the place that you get your care, you go into the emergency room of that hospital, or it's a freestanding emergency, a department with that separately, you have the physician who's taking care of you. And if that physician is an employee of that hospital, which I will say is a general rule, is not the case unless you're going to an academic, meaning, medical school type location with that. Generally, you're not going to find the emergency physicians are being employed with that, so they're their own entity. So you're going to get a bill from the facility, the hospital where you had the services, and then you're going to get a bill from that physician group that saw you. So, it's two different things and what they're billing for the physician is the time and the work that they put in taking care of you. On the hospital side, they're billing you for everything from the supplies to the nurses taking care of you. And if you had imaging studies done, all those different types of things come into play, but you may get more than just those two bills because if you're in the emergency room, what if you had an imaging study, which a lot of people do, maybe it was an x-ray, maybe it was an ultrasound, maybe it was a CT scan. You're also going to have that radiologist who did the interpretation of your study is also a separate entity. So you may be getting a bill for their interpretation of your studies if you had to see a specialist. Let's say the ER physician saw you and thought that you needed to see a gastroenterologist, a GI physician while you were there, or a urologist. Pick a specialty with it and they came in and saw you, they might also, they're going to have a bill for their services. So, every piece of that is separate and distinct. Everything that happened from the hospital's perspective should be all on that one bill for an emergency visit. But those physicians will be separate and distinct again, unless they're all employed. If I go to an organization and I'm at a university, you could pick any university in any state in the country. Those are all physicians that are there. In that situation, you might just see one bill and everything gets put on it. But outside of that type of setting, you would expect to see separate bills for that. Now Jan, my friend, my neighbor, somebody drove her, but if she'd been in an ambulance. She would also be getting an ambulance bill for that too. So, emergency room visits are probably the types of visits where we're going to see more bills than other things that also may happen when some different surgeries and things, but we'll cover that in a separate podcast. But with emergency room visits, you will get multiple statements, bills as a general rule that is appropriate. You still should evaluate'em. You still should make sure that it is appropriate to pay for those particular ones. But again, it is an appropriate practice to have each one billing separately and distinctly for what they did to take care of you. Got a question from Treya. I got a bill six months after a procedure. Do I have to pay it? That's a great question. That's one of those frustrating things that we sometimes get. We've had a procedure done, months have gone by, we think, boy, I paid for everything like I was supposed to. When this bill just comes outta nowhere. It could be a bill from the physician. Could be a bill for something related to it. It could be a radiology bill or an anesthesia bill or anything like that. Well, the short answer is we need to do a little research before we determine whether or not we're required to pay that bill. I always recommend, again, you first go to your insurance company's website, log in, pull up that data service, and look to see did they pay their piece for that claim. Now, there is something called timely filing, which is a fancy way of saying that every insurance company, the physicians and the hospitals know, Hey, you got to get bills into us within this amount of time, 60 days. Six months, one year. Whatever their time period is, you have to get the bill in that time period. And if they don't, then the insurance company says, Hey, too late. I'm not responsible anymore. Medicare's time period is a year. They have the longest time period out there. A lot of the commercial payers, meaning you're Aetna's, your Cigna's, your united. List goes on, they tend to have a shorter time period. It could be 60 days, it could be six months. Again, there's variation and not to go into the weeds, but sometimes state law comes into play and people taking care of the states, they want to make sure. So, again, there's variations, but where you're going to know is you're going to go log in and you're going to look to see, did they pay that claim? If they did, then yes, you have an obligation. It may be frustrating or annoying that you're getting it later. But you have your patient obligation piece that you need to pay. If you see that your insurance company denied it, and said, Hey, you passed the timely filing timeline with it is basically what it'll say, then you do not have an obligation to pay for it either. So, it's on the provider, it's on that physician practice, it's on that hospital to get that bill out the door in a timely fashion for your insurance company to consider payment. And if they miss that window, then that unfortunately is on them. And you do not have an obligation to pay for it with that. And I've had that happen personally in a situation. And again, it's really up to people that are managing the business of medicine to make sure that they're doing things appropriately with that. So, take the time, check the website, see if you have responsibility for that so you can make sure that you take care of what you need to. How do we look at the information from an insurance company and understand exactly what we owe for a particular claim or for a particular service. I know in many of my previous episodes, I've talked about making sure that you log on to your insurance company's website, making sure that you validate what you owe for a service. And we're going to break that down a little bit more today'cause I've received some follow up questions as we've talked through that in some other sessions to say, well, what exactly do you mean by that? And what specifically should I be looking for? So, it's a great question and let's take a step back and let's look at that. So, if you log on to your insurance company's website, and I'll also say separately, if you do receive paper statements or paper information from your insurance company, it's going to be on that information as well. But every time a provider, a hospital, or a physician's office, or anyone even at the pharmacy submits something to your insurance company to be paid or adjusted with that. Then they will send you information back to let you know what they've done on your behalf. And it lets you know what do you specifically owe for a particular service. So, if you log on to your insurance company's website, and every insurance company's a little bit different. But if you look at the headers across the top, you may see something that says claims. That's probably the most common thing that you'll see on an insurance company. That's what my insurance company has on mine. I have one of the national carriers. And if I click on that as a tab, a lot of times right underneath that it will say explanation of benefits statements, EOBs. So, EOB is a short abbreviation for explanation of benefits. And there may be some other things that are under that tab as well. But that's where you can go and pull up all the claims that have been submitted on your behalf to your insurance company from any of your particular providers. Now, when you pull it up, if they were to mail it to you, a lot of times this is exactly what it's going to look like and an explanation of benefits. Usually, we'll have verbiage with it also that says, this is not a bill, and that's because they're just letting you know what it is that you specifically owe related to that encounter. So, a lot of times on the very front of it, and hopefully they do, they'll track what your healthcare costs are at that point, how much you've been billed throughout the year, how much they've paid. They'll even kind of tell you, Hey, we got you this kind of discount. How much money you saved and really have you met your deductible or not'cause that's a big key factor in driving. What is your out of pocket going to be? So, we know we have a deductible that could be anywhere as low as$500. That could be as high as any number, right?$10,000. A lot of times people are in between. And you have that deductible amount, that's the money you're going to have to pay out of pocket. Not counting copays. But the money you're going to pay out of pocket for the services that you received. And once you've met that deductible, then the amount that you're going to pay may be a little different. Up until the point you haven't met that deductible, you're going to be paying all of your responsible items for that. So, usually they'll put a summary at the front of that explanation of benefits. They'll say, who the patient? Is it you? Is it a family member that you're covering? Who the provider was that they paid? What the amount was? What the date of that was? And then, what your responsibility is? And that's what you want to go down and look at a little bit more detail to say, well, how did they come up with that number to tell me what's my responsibility? And sometimes they'll even on the explanation of benefits, explain terms such as co-insurance. For example, if I pull up and I'm looking at one of my EOBs as I'm talking to you, it says co-insurance. When you pay part of the bill and we pay part of the bill, it's a cost share of out-of-pocket amount versus a copay. Which is a fixed cost that you pay when you visit a doctor or healthcare provider. So, we know our copays are a flat rate for that visit, be it an urgent care, be it an emergency room, be it the visit to our doctor or to a specialist. So then it'll kind of get into more detail and it'll show me for each one of these line items, more detail in my explanation of benefits, right. Now, we can see where they came up with that name. So, usually in the first column, it's going to give a description of the services that you received. And it might say, it was an office visit, it might say it was a particular procedure, it might even just say medical services. There's different things that might be listed and it'll have a brief description. And then, you'll see a five digit code, and that five digit code is called a CPT code, and we don't have to get into the details of that. But that's a nomenclature or a coding system of how information gets submitted to the insurance company from your provider's office to clearly identify the services that were provided to you. Then, they'll also have the data service that was on there. So, it's important to look at that and look and see. Did I have those services? Now, sometimes that description may not be very clear, like I can pull up one right here and it just says medical services. It also has a five digit code on there. And I don't recognize any of it. I know from digging into details, that's a lab code. That's okay. The services above there, it gives me specifically what was done. I look at it, go, yep, I had that service. Next column, column A typically is the amount that they bill. Your insurance company don't have the amount they bill. And then the next column gives you the member rate, meaning they've negotiated, they be in your insurance company, has negotiated with your provider to say, we're going to pay X dollars for that particular five digit code that we were just talking about. There's a lot of different things that go into it. All that's not relevant for this conversation, but basically that member rate is what they have negotiated. So, it's always going to be different, and hopefully you're going to see it be a lot lower than what they actually charged. Then, you get into the next column says, pending or not payable, and you may see some notations there. And those are important because if they didn't pay or there's something pending, you want to read the instructions as to why. So, they'll have a little notation with that, and then you should be able to scroll down a little bit further and see the definition with it. The next column will say, what was applied to your deductible? If any of it was, so if you still have a deductible that's still outstanding, they may say, well, gee, you owe$191, but you haven't met your deductible, so we're applying that to your deductible. Or if there's a copay. Now, if it's related to procedures outside of a copay visit, that may be blank as well, and then it'll say, amount remaining. What is the plan paying for that versus what's your co-insurance? So, I've got an example where I had a procedure done. I've met my deductible at this point, they tell me that my member rate for that one particular exam was$191. So, the plan share of that is 80%, but the insurance company is going to cover 1 53 12. My co-insurance amount is 20% of that allowable rate. So, I owe$38 and 28 cents, so I'm able to confirm on that explanation of benefits when I get a bill from my doctor. Yes, I owe them$38 and 28 cents with that. And same thing goes for each individual line item with it. So, go through each individual one. That's going to give you the amount that you owe. Now, back to that. Well, what if they didn't pay? How do I know? Do I understand why? Well, anytime that something is not paid, they're going to have what they call a remark code. And if you scroll down on that explanation of benefit, it's going to give you information as to why it's not being paid. It might tell you that they have requested additional diagnosis information from your provider, your doctor, they might tell you they've requested medical records. They might tell you something is not covered in your plan. This is the information then that's going to cause you to take additional next steps with that. So, again, this gives us an overall basis of how do we interpret that explanation of benefits again. Do we agree with the data service? Do we agree with the services that we provided? We see what they charged. We see what our obligation is for that. And then walk on through the process so that we can validate anytime we get a bill from a hospital, from a physician office, from any type of medical service, whether or not we actually owe that particular amount. So, I hope that's been helpful for you today as you go and tackle and review those EOBs. If you have any questions for me or any other things that you'd like for me to tackle. Please reach out through the website. We'd love to hear from you at takecarepod.com. Until next time, take care.