Bills and Documentation
How to Review Your Medical Bill
After you visit a provider, you may get a bill telling you how much you have to pay. Providers can include doctors, hospitals and others who give you healthcare. The amount you owe will depend on a number of things. Those may include whether you have insurance, as well as your type of plan and its cost-sharing requirements. They may also include whether you received services in or out of your plan's network.
Medical bills may look different, but they all include the same basic information. Your bill tells you the services you received and the dates you received them. It also states the cost for each service and the total amount you owe.
Most often, you’ll get a separate bill for each type of specialty care. For example, when you visit a hospital, you may get a bill from your surgeon, and you also may get a separate bill from the radiologist who read your x-ray.
Before your visit, ask your doctor which services you will get. Ask how much you will have to pay for each.
When you get a bill, make sure it’s right. Look for overcharges, double-billing and incorrect dates of service. Ask about any codes you don’t understand. If you believe there are errors in the bill, even minor ones, contact your provider.
If each procedure or service isn’t listed separately, ask for an itemized bill.
Make sure the procedures and total payment amounts on your bill match your explanation of benefits (EOB). If the EOB is not right, contact your insurer.
Use the FH Consumer Cost Lookup to compare the charge amounts on your bill with what providers typically charge for the services you received.
Keep records! Save all receipts as proof of payment. Write down your healthcare visits and services received. Record the names of providers, bills and the amounts you have paid with the dates of payment. This helps avoid confusion if there is a question about whether you paid a bill.
If you can’t pay, act quickly. Contact your provider to talk about lower fees or payment options.
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Explanation of Benefits (EOB)
After you get care, your provider sends a bill, or “claim,” to your insurance company. Your insurance company handles the claim and sends you an Explanation of Benefits (EOB). The EOB is a summary of the services you received and the date they were performed, how much your provider charged your insurer and how much your insurer paid. The EOB may also include the amount you have paid toward your deductible.
An EOB is not a bill, so you should not make any payments based on this information. You will get a bill from your provider or hospital if you owe a balance.
Is the EOB related to a claim for which you already paid the provider? If so, it may contain a reimbursement check. In that case, you will see an area on the EOB labeled “payment enclosed” or “issued amount.” Be sure to cash the check promptly and to keep the remaining part of the EOB for your records.
Most EOBs start with identifying information specific to you and your plan, and list the services you received. If any of this information is wrong, contact your plan. If you have questions about your EOB, talk to your plan. If you believe that your claim was not resolved the right way, tell them. The phone number is on the EOB.
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Code Modifiers: How They Affect You
Doctors and insurers use standard codes for each medical service or supply. That helps them communicate about treatments and payments clearly. Current Procedural Terminology, or “CPT®” codes, stand for specific services, like a 10-minute primary care visit. For supplies and equipment like bandages and crutches, there are other codes called HCPCS. (It stands for Healthcare Common Procedure Coding System.) CPT codes start with a number, while HCPCS codes start with letters. You may see both CPT and HCPCS codes on your bill or Explanation of Benefits (EOB).
CPT codes are five digits long; HCPCS codes are one letter plus four digits. Both types of codes may be followed by a two-digit number called a modifier. That gives the insurer more information to adjust their payment. For instance, if you had more than one x-ray in the same visit, the modifier will show that. If the code you see is seven characters long, a modifier has been added.
Why do modifiers matter? If you go out of network, your plan may have limits on what it will pay. Modifiers can be used to help identify those limits. For instance, suppose you get two surgeries during the same operation. Some plans may agree to pay 100 percent of their allowed amount for the first procedure. But, they may pay only part of the allowed amount for the second one. Your plan will know what to pay because your doctor will include modifier 51 to show you had more than one procedure.
Does your bill or EOB seem high, or do you think you see an error? If so, ask your insurer about the codes on your bill or EOB, and make sure they show the services you received.
CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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How Medical Supplies and Ambulance Rides are Billed
Medical supplies and equipment, such as bandages and wheelchairs, and ambulance rides are often listed separately on bills and Explanation of Benefits (EOB) forms. They use a standard code called HCPCS. (It stands for Healthcare Common Procedure Coding System. Sometimes it’s pronounced “hick-picks.”) Each HCPCS code stands for a specific item, and helps your insurer understand what supplies and equipment you received.
A HCPCS code starts with a letter, followed by four numbers. A two-digit code modifier may follow, giving your insurer more information.
Understanding HCPCS codes can help you plan your costs when you need care. Before you get an elective procedure, like knee surgery:
Talk to your doctor and ask what supplies you will need during and after the procedure. Ask which HCPCS codes will apply.
Use FH Consumer Cost Lookup to get a sense of how much these supplies, identified by their HCPCS codes, usually cost in your area.
Then, to find out what will be covered, look at your plan description or ask your insurer.
Are some supplies not covered, or are you going outside your network for care? If so, ask your doctor about lower-cost choices, like renting equipment instead of buying it.
After your procedure, review the codes on your bills and EOBs. If you find that a code is wrong, ask the provider to fix the error. Then, resubmit the claim to your insurer.
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