When you understand a certain particular process, you can have an easier time dealing with its complexities because you know how.
Medical Billing may sometimes be considered a mystery but when you have the knowledge of this process you have a better control of your financial responsibility and obtain peace of mind.
Your overall health care experience is but stressful.
The Health Care Industry is the most complex trade.
A part of this industry is the Medical Billing and Collection processes that have not been, for the most part, clear to patients, for example, the pricing.
How does the industry come up with the calculation to arrive at the recommended chargeable amount for services, procedures and supplies, never mind the ever increasing prescriptions drugs? To answer this particular question is to point at some areas of consideration, the running expenses in the provider of medical services, for example.
The Doctors' services are provided an allowance for overhead expenses in determining reimbursable rates or initial cost of the service.
Arriving at the bottom line is of complicated nature and I am not an expert to decipher this area.
I can only direct readers interested to know (unless you are in the medical billing business familiar with RBRVS), you can solve a 1000 pieces of puzzle easier than you can even get to a couple of pages of RBRVS book if they are available to the public.
And then there are the Codes (known for short, CPT codes).
CPT stands for Current Procedural Terminology developed by guess who? The Doctors themselves, the American Medical Association.
This code book is used to identify the services (includes procedures and supplies).
Mind you, there are also "local" codes used depending on type of insurers.
So many books and manuals to use to prepare one claim for submission to insurers for payment.
It would be highly effective if patients will have copy of this just like a dictionary, a thesaurus or any look up books for its own understanding and to gain knowledge.
As commonly known, the above mentioned information is commonly UNKNOWN.
Patients may not be aware of the level of service coding and the additional codes for the diagnoses, let alone the pricing.
Only Self-Paying patients (no insurance coverage) do get to know the cost of intended service since they are required to pay up front.
In terms of financial responsibility, patients may feel comfortable after a doctor's visit, knowing that they are fully covered with 2 insurances, i.
e.
primary and secondary (supplemental).
In most cases, they should feel at ease.
They do not need to worry about receiving any statements for balances or receiving a courtesy call from the doctor's office, etc.
It is ideal that way.
But, this is the big but, what if you just recently changed your coverage and did not really pay attention to your, say, supplemental?.
Perhaps, you were excited to see a smaller premium than your previous ones, therefore bought it and changed your insurer.
Then you get a surprise statement reflecting a balance after both of your insurers have paid for the service rendered, you thought? Well, you may find that after all the excitements on lower premiums and lower co-pays, you might end up paying more.
Your supplemental coverage was only paying 50% of the co-responsibility therefore, you as the patient still end up paying the balance.
All of a sudden your visit to your favorite doctor became disappointing, not the service or the doctor, just your insurance.
It is so ideal and should be a typical process when the service is rendered, the billing clerk puts the billing together and sends it off to the clearing house or directly to the insurers for processing for payment.
Seven days later, the Doctor gets paid.
A very ideal scenario that Doctors' offices always wish for.
The patient's insurer's payment is accepted as payment in full if the Doctor or provider of service is under contract to do so.
However this ideal scenario is only a fraction of what goes on with patient's medical billing.
The odd scenarios unfortunately, may be contributing to the ever increasing health care cost.
All parties involved in resolving problematic medical bills can cost the Doctor's Office, the Insurers personnel expense.
Remember that the setting up of pricing or fees schedule considers allowances for overhead expenses in the Doctor's operation? I can not speak for Insurers on this part, they have their own battle to wage.
In some instances also, the interpretation of contracts, covered benefits and the coding itself play a big role in some of its inefficiencies.
Another area that may play a role is the many variations and benefit interpretations in patients insurance covered benefits.
Government rules and regulations and the insurance companies may even have a wider range of variable interpretations.
Even the insured may not be aware (or confused) of most of their own benefits or the lack of.
Knowing the types of insurance environment and classifications will also educate patients in handling their medical care activities, in addition to learning the most common alerts, i.
e.
What is Advanced Beneficiary Notice (ABN)? What is Assigned and Non-Assigned Claims or Providers of Service? Be Aware of these two important parts of your billing (financial) responsibilities.
Last but not least, be your own watchdog.
There are advocacy groups that will help you ease through these billing challenges.
With the help of the internet, just type in your inquiry and search.