The medical coding and billing process is a part of the medical industry that is now so complex, that colleges actually offer courses in this topic!
Medical billing in America is almost always a lengthy and stressful process now. First, your diagnosis and treatment records are submitted by the care provider to a medical biller. The medical biller then creates a billing record and submits it to an intermediary source, who edits your billing claim to meet insurance company criteria.
Next, the intermediary sends your medical bill to the insurance company to process the payment, and it is here where many problems occur.
And they happen at this particular stage of the billing process because the insurance company will conduct a series of “tests” on your bill to determine whether or not they will pay the claim. These tests include determining the patient’s eligibility for payment, the credentials of the provider, and the necessity for medical assistance in your case.
And believe it or not, sometimes the determination of whether your bill gets paid, and how much the provider is allowed to charge, depends greatly on the relationship of the insurance company with the medical provider. It’s actually possible (and likely) for the exact same procedure to cost two or three times more simply depending on which insurance company is handling your claim.
If, and only if, certain conditions are met and tests are passed, will your insurance company pay your billing claim. If not, then your claim is rejected and has to either be edited to pass the insurance company tests, or has to be paid by you.
Sounds complicated, right?
It certainly is, and the medical billing process has caused financial hardship, stress, and wasted time for many Americans. Insurance company claim rejections occur in almost 50% of cases, which can leave you, the patient, without recourse and faced with the prospect of having to spend your time, money, thought, and energy resolving the issue.
This is why understanding medical billing is extremely important. Because in the event that you are overcharged, or your medical claim is wrongly denied, you need to know what your options are and how to resolve the situation effectively.
In most cases, medical billing claims are denied because of medical billing mistakes. These mistakes can cause your bill to fall beyond the scope of your insurance coverage, and commonly include things like having your diagnosis reported incorrectly, or not having one reported at all.
So, what can you do if your claim is denied?
Well, first, you need to realize that help is available to you, and you do not simply have to give up and pay the bill yourself.
Consider hiring a medical billing advocate who can help you negotiate your medical bills down to a much more realistic cost.
With the medical billing system being as complex as it is, it takes a specialized set of skills to handle denied medical billing claims effectively. A medical billing specialist should be able to help you find and fix mistakes on your medical bill, re-submit your claim, and negotiate with your insurance company and hospital to make absolutely certain that the bill you end up paying is legitimate.
Also, many medical billing advocates will represent you for no up-front cost, and will only take a percentage of what they end up saving you in costs.
But is it possible to get your claim reinstated on your own? Yes.
But you need to be prepared for a long, tedious, and time-consuming uphill battle.
Many people who have tried to fight to get their own medical bills corrected have reported having to spend dozens or hundreds of hours on the phone, and writing letters to various insurance company representatives, only to have the insurance company deny their claim yet again, or find that their debt has been sold off to a collections agency.
It is strongly recommended, if you choose to go this route, that you document every phone call and conversation you have. You’ll need this documentation in order to have some way of holding your hospital and insurance company accountable, and avoid being bounced back and forth between them.
However you choose to go about handling your medical billing claims, remember that it is the insurance company’s duty to provide you with the coverage that they’ve promised you. So, don’t give up until you’ve gotten the results that you deserve.
But if you find that you are making little progress on your own, or choose not to try on your own at all, our staff at Medical Bill Rehab can help. We will review your medical bills and let you know whether we can work on your behalf. If we can, you pay us only a fraction of the savings we create for you.
Now that you understand medical billing and its complexities, it make sense to have an expert on your side. Contact us now and let’s talk. You deserve to pay no more than what you really owe (and perhaps a lot less).