I need someone here who works in the medical or the health insurance business to 'make attempt' to explain how medical billing operates and what my legal obligation is to pay ANY invoice that a doctor or hospital sends me.

I have good Blue Cross/Blue Shield insurance with a $2,600.00 deductible. Most of the major services I have received in the last 8 months have required a $350.00 co-pay prior to getting service. Also, all doctors and hospitals have a form that you have to sign that says " the patient is responsible to pay all charges that his/her insurance does not pay".

If you happen to ask what these 'residual charges' may be,...you will get a stock answer from medical billing personnel that says

" we can't answer your question until we finish billing your insurance company".

Once a month, I get a statement (not an invoice) from Blue Cross telling me the amount the doctor or hospital billed the insurance company. Blue Cross never pays the total billed amount (which is grossly inflated) and discounts the total amount by some percentage (sometimes 50-75%) and then pays the hospital or doctor the reduced amount. If there is any shortage between what the insurance company paid the provider, I get invoiced for that amount.

The problem is you never know what that final residual payment maybe. Sometimes it is $100.00 or $500.00, or $2,500.00 and 2 months ago, I got an invoice for $20,000.00 !!!

WMH,

I have a $6,000.00 cap and just yesterday Blue Cross told me on the phone that I have met it. What does this mean?

A "Cap" or a yearly out of pocket is the maximum amount you have to pay in any given coverage year. So once you hit $6000 you're done paying until next year. Fyi, this does not always mean a calendar year. For example, I get health insurance thru TriCare for Military Reservists, and they resets at the beginning of the Federal Fiscal year, which is Oct 1st.

My statements show how much of my deductible I've paid and how far I have to go before reaching the cap. Check your statement, but if you talked to someone and they said you already met your cap...then you're done, for now.

P.S. Yes, if you don't pay medical bills they can affect your credit. They can turn you over to collections and all that nasty stuff.

If you suspect you are not being billed correctly, you'll need to contact your medical provider's billing center and discuss. It can be horribly confusing, but if you're seeing duplicate charges that's one key area to discuss. Most often, your insurance company is double checking these things too because THEY are usually paying more out than you are (80% vs. 20% or whatever your cost share is). But that doesn't mean they don't miss stuff. The worst is when the medical provider charge you for something that never happened...but it's hard to keep track if your out cold (i.e. sedated) for example.

Sid,

I need my basic question answered,...will I get sued if I don't pay the 'residual invoices' sent to me by the hospital or the doctor?

I used to work as a case manager/ UR nurse. Most "in-network" physicians and hospitals have a contract with Blue Cross and other insurers that DO NOT allow them to "balance bill" the insured person. Blue Cross has negotiated the rate with the provider, and signed the contract. The insured person will still have out of pocket expense due to co-pays and deductibles, but they will be much less than the "balance" of the inflated charges. Many physician offices and hospitals have billing offices that will still try to "balance bill" patients.

Never pay a bill based upon what they physician/hospital bills you. Your insurance company will send you an "Explanation of Benefits" showing the billed amount, the contract discount, the amount the insurance company paid, and the amount that you owe. Pay your bills off of this amount. I have even stapled the EOB to the bill, circled the amount due on the EOB and mailed this together with my check.

You can also go on-line and look at your EOBs. In my state, Blue Cross has a great on line system that makes tracking insurance claims very easy. You can also print your EOBs from the on-line portal.

Rathrum -Thank you that information. Every little bit helps here.

Last March, I learned the 'hard way' what it means when you use services that are considered "out of network". Last March, I had to call an ambulance for myself and that ambulance service did not have a contract with Blue Cross. I got a $1,200.00 invoice for that 3 mile trip to the ER. Then it turns out, the hospital they took me to was

Roy, if I remember correctly, you are self-employed.

If you still work for a company, asking HR to help would be the easiest way to get some answers.

Several years ago, I was going round and round with stupid healthcare payments (United Health) being incorrectly coded and therefore the insurance wasn't making payments. Even AFTER the correct codes were sent to them, they STILL denied. Called HR, and they took care of it.

All of our healthcare bills... insurance appears to have a "deal" with the provider that Service X only costs 75% of what the clinic or provider charges. We are not billed for that 25%. It is written off.

I agree with Rathdrumgal.

Right on my EOB page, it says that I am not responsible for anything other than what my insurance co has deemed reasonable and customary. "Patient not required to pay" is exactly what it says.

Susan (OH)

Allow me to read directly from my latest statement (Claims summary as BC/BS calls it):

Doctors Fee: $1,800.00 (amount billed to BC/BS)

BC/BS Discount: $1,067.80

Amount BC/BS paid: Zero

Amount Owed to Provider: $732.20 (The doctor's billing company sent me an invoice for this amount).

On a 2nd page in the same envelope, there is another Claims Summary statement. It reads as follows:

Outpatient Clinic: $3,500.00 (amount billed to BC/BS)

BC/BS Discount: $2,550.00

Amount BC/BS paid: $652.04

Amount Owed to Provider: $297.96

I paid a $350.00 co-pay here. Does that account for anything? Who pockets the Co-Pay? The doctor or the clinic?

Roy - I'm not the expert that many here are but I do have a dependent with significant medical expenses and we have dealt with some of these billing issues. On the last post you made where you listed the amounts - it appears that your insurance has not paid these yet and the clinic is sending you the bill. Before you pay these do as suggested above compare to your EOB. Getting online access set up is very beneficial as well because you can go online and see what claims have been submitted that are still in process. We have been billed for things that the insurance company was still processing that insurance wound up paying in full. One final thing - the way these claims are paid is crazy as well. There is some sort of clearinghouse set up for medical bill payments. When your insurance company pays a bill it goes to this clearinghouse, not directly to the billing clinic. The clinic has to go grab it from the clearinghouse. If they don't get it within a certain number of days then the payment goes back to the insurance company and they have to pay it again. We have had multiple instances where the EOB was showing that the insurance company had paid but the clinic claimed to not have been paid because they didn't grab the payment.

Bottom line is that medical billing and payments are an absolute mess and it's a shame that people who are already dealing with a situation with their health have to deal with it at a time when their stress level is through the roof and their capacity to take on more is diminished.

Roy,

My understanding is the co-pay is applied toward the entire bill AFTER insurance negotiates their discount.

Let's say you pay $350 up front.

Dr. office sends bills for $1000 to insurance.

Insurance reduces the bill to their negotiated "allowable" rate to $500. You already paid $350 so only $150 remains due. The insurance will then pay if you have surpassed your yearly deductible at whatever cost-share split you have (80/20 or 70/30 is common), or you will be responsible for the full $150 if you have not yet met your deductible.

As razorback says, the billing process takes time depending on how speedy your insurance company is processing claims. Some doctor's offices will refuse service after x-days and the bill isn't paid, which kind of stinks when the insurance company is dragging their feet. To ensure you still get to see your doctor you might have to pay up front and be reimbursed later once insurance finishes their process. That's one area I have never had to deal with so I suggest calling your insurance provider to find out what's going on with bills you are receiving from the clinic.

It's confusing.

That's how it works on all my bills. Different providers may do it differently. Sorry I don't know everything yet...workin' on it. (wink)

To use your numbers, it sounds like you have two separate bills with a remaining amount due now that insurance has said what their allowable amounts are...

Bill 1 Dr. Fees: $732.20

Bill 2 Clinic Fees: $297.96

Total due: $1030.16.

My understanding is your copay of $350 is applied at this point, leaving a balance of $680.16 that you, your insurance company, and/or both of you will pay. I could be wrong, so be sure to ask your insurance provider.

Btw, to be clear, many doctors may have either solo or partner practices, but they all fall under a network of physicians affiliated with one or more local hospitals. The clinics are also run in the same way, falling under a network of clinics tied to one or more hospitals. So it's not correct to think in individual terms of "who pockets what"...the money paid in by you and/or your insurance company goes to the network/association based on their terms, and then clinic/doctor/nurse expenses and salaries are paid out of it based on the patient load / work performed. Doctors who have their own practices make more when they have lots of patients and are constantly busy servicing more patients vs. "staff" physicians who just hang out at the ER or urgent care clinics and earn a set salary regardless if they treat 1 or 100 patients per day.

A friend of mine who is a doctor tried to explain this too me once and I felt like I was waking up after a night downing a case of Coors....

Oh, JR,..you made a classic mistake. Admitting you are an MD,..that's why I never divulge my REAL job.

Roy

Wait until the dust settles on all the bills. Pay nothing, yet.

You are self employed. I am willing to bet that "on paper" you are a poor man (meaning your taxable income on your tax returns minus all your deductions).

Any hospital I have ever come in contact with has the ability to knock down the amount you owe.

A few years ago I had major surgery. My total out of pocket was $4650.

I waited and did not pay anything until they threatened to turn me over to collections. (about 9 months) Then I contacted their billing department and provided my tax returns. They knocked 90% off my bill. YES YOU READ THAT RIGHT.

My bill went from $4650 to $465. I then waited to pay that until they again threatened collection; about 3 months.

I had overpaid insurance on one my escrow accounts and was sent a check for $375. I called the hospital and said I could only pay $375. They took it.

Roy, I feel for you. I had two VERY sick relatives that I've cared for the past two years. I called about a bill the other day and a very helpful young lady told me not to pay it that the insurance just paid it. I then said something like "thank goodness, that should be the final bill". Nope, she told me there are some outstanding from February that are "back at the physician's office", there are some from May that were paid by BlueX, not paid by the secondary insurance and were resubmitted and apparently those are scheduled to be paid. My sister paid some bills without checking and a partial refund came ... supposedly they paid an old unpaid invoice from January ...although I know for a fact there were no final unpaid invoices that we saw. The bill was paid from his personal checking account. The refund check came payable to his estate. no one told them there was an estate ... there isn't one ... so I can't cash the check.

"we will bring you what we think you need and then send your insurance company an invoice first and then you will have to pay WHATEVER AMOUNT your insurance company does not pay!!!"

YEP! This is the problem. You agree to pay a bill without knowing the cost.

Medical bills will show up on your credit, but almost everyone I deal with doesn't count them. I know I don't with prospective tenants.

Prior to ACA, I had a 80/20 insurance with no real cap on total out of pocket. I had a gold plated hysterectomy. I owed $14K and they wanted it paid off in 2 years. (Essentially they wanted me to buy a new car and pay it down in 2 years!)

No way I could do that and still pay for my monthly premiums. I paid $50/month, they wanted more. Too bad. Occasionally they would call me and try to threaten me to pay more but I ignored them.

Now, I have an accountant who pays my bills, so a couple of years ago, it occurred to me to ask her status on that bill. She said, "they quit sending me an invoice, so I quit paying it." I checked my credit and nothing is there. I assume they wrote it off.

BTW, unlike the above poster, I called to get the bill reduced and they wouldn't budge. ;(

sid,

How do you know so much about medical billing and insurance practices?

Allow me to throw a curve ball at you here. While I was undergoing cancer treatments (Dec. 7th - May 31st), I was treated by 3 specialists who were Employees of the teaching hospital (UAB) which I attended on a regular basis. Again, I asked each of these 3 specialists if they were Employees or in Private Practice and they each confirmed they were Employees of UAB.

Now, whenever I was treated by one of these 3 specialist, that specialist would send their own invoice to my insurance company and the hospital would also send another bill to my insurance company (it appears to be double dipping going on here). Is there any justification for this? Employee/staff doctors billing the insurance company for their services when they receive a normal weekly paycheck from the hospital???

Roy, sorry for the delay in getting back to you. As you now know, medical billing is unbelievably complex. As others have said, much of the confusion stems from your medical providers billing you for the balance of what they feel you owe when they haven't settled up with your insurer yet.

If you have reached your out of pocket maximum for the year, you probably are sitting pretty well as far as your obligations go.

How many different providers are sending you bills now?

My best advice for you is, as tedious and time consuming as it will be, is to request an IN PERSON meeting with the billing folks of every one of those organizations, starting with the largest balance due and working your way down. State that you are an upstanding guy who pays his bills, and you just need a good explanation of your bills and balances. Also, request that the billing person call your insurer while you are present to work this out. Be unerringly polite (I m sure you will) bring a support person with you, and take or have your support person take copious notes: dates of meeting, persons present, items discussed, specific dollar amounts, etc.

and what about "coding"? apparently that's done wrong quite often ... and no one catches it.

Thanks JR for your reply. I will take your advice and start negotiation ASAP. I will be nice too.

For those who have negotiated with hospitals or doctors,...what is your negotiating strategy? I mean what do you tell them in hopes of getting a significant reduction in what you owe? Do you have to humiliate yourself by begging and/or pleading poverty?

That 10 dollar trick may not work in many cases. They can charge you 12% per annum interest, and they are not obligated to accept a small amount if you have the ability to pay more. If they turn it to a private collection agency they can pursue your ability to pay. Ie try to pay your credit card this amount.

I've taken several tenants and other people that had business debts and that owed me money who tried this. The judge reviewed their income via either their tax records or a CPA statement and ordered them to pay more and one had his wages attached.

Roy, I wouldn't try to negotiate any balances until you have exhausted getting an explanation of what the service was, what your insurance paid, if the account is still open with a possible insurance payment pending. Many, many times, by just seeing this through, the end result is the patient owes nothing or a trivial amount. Also, if you ask nicely, I am confident the hospital will put your account status on hold, that is not send to collections, etc. while the dispute is in resolution phase like this.

Every hospital has a free or reduced charge plan. At my organization, if you earn for example, less that $30,260 for a family of two, you ar probably entitled to have your balance reduced. Unfortunately, I see on the UAB website they consider any of a patient's assets over $6,000 with the exclusion of a primary residence as fair game unlike our program which is income based only. Doesn't hurt to ask, though.

So, after you determine that there is a balance due to you, that your insurance will not cover (don't forget to exhaust all appeals with your insurer,too which will take a long time but I'd estimate has a bettter than 50:50 chance of success, your hospital billers will help with the appeals) then and only the discuss payment. Larger institutions like a hospital have a formula for the amounts it will accept, and HOmers $10 a month plan wouldn't fly around my workplace, We require 5% of the balance paid every month, up to about 20% of the patient's net income. Smaller providers, like a doctor's office, are more willing, in my experience to offer the 70% discount than the bigger ones, but it doesn't hurt to ask. Note that at a larger institution, the billing person you will be speaking with will probably not have the authority to give the discount, they will need to run it by a manager, just like the car dealership.

JR,

Thanks for that additional information. A few months ago, when I received the $20,000 invoice, I sweated for a week over what to do about it. I finally got the nerve and called my insurance company to make sure these residual charges were correct. As it turned out, BC/BS told me I did not have to pay that $20K amount since they were getting ready to pay it. In other words, it resulted from being in-between billing cycles between the hospital and the providers.

In the last 8 months, I have received numerous invoices and I have promptly paid the ones that I considered 'reasonable'. The unpaid invoices that I have sitting on my desk are ones I consider unreasonable and these I will be calling about today.

Again, I appreciate the information you have provided. FYI: Next Tuesday (15th), I am having cataract surgery in my right eye. At this writing, I do not have the foggiest idea of what this is going to cost. The receptionist at the Ophthalmologist's office, causally said,...'don't worry about it,..we will bill your insurance company'.

If you are going to an in network doctor this means the doctor has accepted the rate your insurance pays for the procedures they are doing and they cannot bill you for the difference. There are some exceptions like if you are at an in network hospital and see an in network doctor but then they bring in an out of network specialist, and depending on state law you may still be responsible for those bills. If you are going to an out of network doctor it depends on the type of insurance you have, but generally they will cover a set amount and then you are responsible for the remainder. So if you are seeing an in network doctor you shouldn't be paying any bills beyond your deductible, copay, and coinsurance.

Do you have to humiliate yourself by begging and/or pleading poverty?

No humiliation or begging. "I can't afford this, can I get a reduction on what I owe?"

They will likely ask for your tax returns to prove your income. Look on their website if they have one, it should be outlined there.