Fredrick Insurance Brokers Podcast

Claims Decoded: Understanding the Agent’s Role vs. Your Responsibility

• Katherine Clark & John Fredrick • Episode 2

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0:00 | 13:05

Regarding Claims, What Is The Agent’s Role Vs. The Consumer’s Responsibility?

Health insurance shouldn’t feel like a guessing game, and medical bills shouldn’t read like a puzzle you’re paying to solve. We pull back the curtain on why most claim problems start at the provider, how to use your Explanation of Benefits as your North Star, and what steps turn confusion into control. From the first phone call to a clean resolution, we walk through a clear process that helps you avoid overpaying, challenge errors, and get fair outcomes.

We start by clarifying the agent’s role under HIPAA: we can guide, educate, and escalate, but your permission and participation unlock real progress. Then we dig into the EOB—what it shows, how to spot mismatches with an itemized bill, and the red flags that signal a claim was never filed. You’ll hear why miscoding can follow you, even shaping eligibility and underwriting, and how a simple code correction can shrink a bill and protect your medical record. We also explore price transparency: why hospitals often charge more than outpatient centers, how procedure prices vary across town, and which tools reveal local and national ranges so you can negotiate with confidence.

Real stories ground the advice, like cutting a surgery quote from $23,000 to $11,000 by referencing market rates. We make the case for a simple system: don’t pay the first bill, gather the EOB, document every call, verify preauthorization, compare codes, and negotiate. And when a suspicious late bill lands months or years later, we explain how timely filing rules and good records help you push back. The big takeaway is empowerment—ask questions, expect proof, and remember that you are the customer. Bring notes, bring data, and don’t be afraid to say no until the numbers make sense.

If this helps you breathe easier, follow the show, share it with someone untangling a bill, and leave a quick review so others can find it. For personalized guidance, schedule a no-obligation consultation at FredrickInsuranceBrokers.com or call 972-375-0507.

To learn more about Fredrick Insurance Brokers visit:
https://www.FredrickInsuranceBrokers.com
Fredrick Insurance Brokers
Dallas-Fort Worth, Texas
972-375-0507

SPEAKER_00:

Welcome to the Frederick Insurance Brokers Podcast, where health insurance finally makes sense. Your hosts, Katherine Clark and John Frederick, are independent health insurance specialists and co-owners of Frederick Insurance Brokers. Family-owned, faith-grounded, and serving individuals, families, the self-employed, and small businesses across the country with options instead of headaches. Around here, they're known as Health Insurance Brokers with a Heart, guiding you toward quality care that's simple, affordable, and aligned with real life. So if you've ever thought health insurance is confusing, expensive, and definitely not fun, you're in the right place. Let's dive in and take the fear out of coverage one conversation at a time.

SPEAKER_01:

Hi Julie, happy new year.

SPEAKER_02:

Happy New Year. We're excited for you to break this down for us. Let's jump right in. Regarding claims, what is the agent's role versus the consumer's responsibility?

SPEAKER_01:

Well, unfortunately, the agent's really just there for moral support because of HIPAA. A lot of the carriers are not going to have a conversation with the agent about it. Some carriers will let the client sign a HIPAA authorization form, but as an agent, I'm there more to guide or if things kind of need to be escalated, but it really is the responsibility of the client.

SPEAKER_02:

And when a claim issue does come up, what's the very first step that you tell your uh clients or consumers to take?

SPEAKER_01:

Well, the first thing I ask them is if they have an EOB that stands for explanation of benefits, because that is if there's no EOB, that sort of tells me a few things, like then nothing has been filed, which happens, or if I see that EOB, I can kind of determine what's going on because it lays things out. So that's one of the things I ask them to do. I ask them that going forward to take notes of who they speak with, when, dates, and times, that's really important. Because in this day and time, the provider will tell you one thing, but unfortunately, nine times out of ten, a claims issue is due to the provider, not the insurance company. And so I asked them to keep notes about that because, for example, if you know Cindy at you know Dr. Jones' office says, I called your insurance company. Okay, what day did you call? Who'd you talk to? What did they say? And that's like standard operating procedure. They should have that information, and if they don't, unfortunately, that falls more on the patient or the client. They need to hold them responsible, so they need to document what's going on.

SPEAKER_02:

And you mentioned some of the mistakes that occur, and you see them often by the provider. You also mentioned the EOB. I didn't realize that that's something that is missing in the beginning of this. Would you say that's one of the biggest mistakes that you see?

SPEAKER_01:

Um, I don't know if it's the biggest mistake. I see a lot of miscoding. We all know what credit bureau reports are, right? And if you get a bad credit something on your credit, how it messes your life up. Well, imagine uh a bureau called a medical information bureau report. Something is miscoded, it can really mess your life up. And I'll give you an example. Um, I have a client who has a medication that she's using for her skin, but it's also coded in that it can be used for a person with a heart condition. So if it's not coded properly, then she looks like she has a heart condition. So there's a lot of things that we as normal consumers don't think about, but in the background, so um it miscoding is is one. Um sometimes they don't even file, but they say they have. Um, they don't call the right number or call to get pre-authorization, and it's just in this day and time people just don't seem to do their job, and so that falls on us, the consumer, where we're having to sort of do their job for them, which is you know, so I will tell you again, nine times out of ten, it is the provider's problem.

SPEAKER_02:

And as consumers, what can we do to help us stay organized? What do you recommend for us to do in terms of like keeping a log of the communication between us and the right?

SPEAKER_01:

You're gonna want to, you know, make the notes so that you can. Well, number one, if it ever gets to me and I have to escalate it, having a copy of those EOBs, having the notes of who they're speaking with at the provider's office, especially if they provide their notes, because if they've talked to somebody at the insurance company, that really helps me when I escalate it to hold them responsible. So you just have to keep notes of dates, times, who you spoke with, what they're telling you, and that sort of thing, because it's just a guessing game, otherwise, right? So again, it's unfortunate because we have to do their job for them. But and then, of course, like I mentioned, that EOB. That EOB, by the way, provides a lot of information. If I see it, I can tell if they overcharged. Sometimes I can tell if they've miscoded it, I can give my clients some resources to go look up charges to see if they're charging a reasonable charge. So that in itself is a little bit of an education, but once I walk a client through how to read an EOB, I mean it makes sense. It sounds like a, you know, because it's new, it's like, oh my gosh, what is it? All these medical terms, but really there's like about five columns. It's it's pretty simple, but you just need someone to walk you through it once so that you understand it.

SPEAKER_02:

And Catherine, what you said too was really interesting about the charges that you can actually look at those fees and see if it makes sense. Do you find that the charges have fluctuated a lot, like year to year, of what you expect? And how do you reference this? Because I imagine that that's a lot of information, a lot of different conditions and you know illnesses you're looking at.

SPEAKER_01:

It's not so much year to year. I mean, interesting enough, you can, you know, there's certain areas of town, you know, where you have two or three hospitals like in a row on a main road or something, and you could go to each one and get a different price for the same thing. Um, hospitals are always going to charge more than um than like outpatient facilities. And there are literally state-of-the-art outpatient facilities that doctors have privileges in that are just as good as hospitals. They just don't have that overhead of all the administrative things in the hospital and such. Um, there's one in Dallas and there's one in Oklahoma that the one in Oklahoma has been around a long time you could go to and have a surgery done and stay in a five-star hotel for recovery and still pay less than what you pay in a hospital year. So that's there are resources online where you can put in the code or the procedure you're gonna have, and it will show you locally, regionally, and nationally what the pricing is. And um, I'll give you a really good example. I had a person call me from a surgeon's office. They needed a plate in their ankle, they had broken their ankle and they wanted to charge them$23,000. I looked it up and I said, Well, here's the price. They turned around and told them it was$11,000 and they agreed to do it for$11,000. You have to know what you're doing or ask questions, you you know, and so that that sort of leads me into another thing that I've always said is don't pay the first bill, don't accept what you're told right away the word the first time, because the days are gone. Listen, I'm old, okay. The days are gone where you can just trust that the bank's gonna get it right, right? That everybody's gonna get it right. So there's nothing wrong with asking. You know, my son's first child, two years later, he received a bill for the nursery, and I said, do not pay that. Okay, because number one, don't bill me two years later, do your job. Number two, I guarantee you he already paid for that. But you know, if they send it out for all the kids that were born during that time and they get half that money, right? So you just you can't trust those things, and so you always should ask.

SPEAKER_02:

Yeah, that's a great point. Now, when is it too late for a provider to send in, you know, a bill? Because, like you said, you know, your son got a bill two years later, and you know, we've experienced two in this household. I mean, is there no limit?

SPEAKER_01:

You know, I I don't really know the answer to that question, but what it make what makes me think is that there is a limit because you know there's a limit when the insurance company is going to pay. They usually have like somewhere in the neighborhood of 120 days. So that's just to me common sense. Somebody sends me a bill two years later, too bad, too sad, right? That that doesn't that's not good business, and so I I would not consider paying anything that came to me way late. Um, I feel like that it's so confusing to people because they, for example, don't understand an EOB. If they went back and looked at an EOB, like for example, my son, and we if we went through that line by line, I'm sure that we could find he didn't make that payment. Okay, but other people don't. They just think, oh, well, they must have made a mistake. So you know people paid it. And you know, so they probably sent it out to you know, a thousand people, kids that were born that year or something, right? So this kind of stuff does happen every day. I mean, probably millions of times a day. So you should always question and don't be afraid to question. My motto is everything in life is negotiable. So, you know, we we get this feeling sometimes, like doctors and lawyers, and maybe realtors or even insurance brokers. We get this feeling. I guess insurance brokers don't really fall in this category. We get this feeling that uh we work for them, but it's the other way around. Okay. So you can ask. You can ask about a bill.

SPEAKER_02:

Well, Catherine, thank you so much for breaking that down clearly. It was very helpful, and I think a lot of people are gonna appreciate what you just said.

unknown:

Great.

SPEAKER_02:

That's what I do. I aim to please. Well, I I'm pleased, and I'm gonna go look at some medical bills after this.

SPEAKER_01:

It's worth it. It's worth it. Some you can find find some money.

SPEAKER_02:

Absolutely. All right, Catherine, we'll see you next time. Thank you.

SPEAKER_00:

You've been listening to the Frederick Insurance Brokers podcast with Katherine Clark and John Frederick. Health insurance brokers with a heart. If you're ready for health coverage that actually fits you, not the other way around, schedule a no-obligation consultation today. Visit Frederick Insurance Brokers.com or call 972-375-0507. Because peace of mind shouldn't be a mystery, and your health insurance shouldn't need a translator.