You’ve worked hard to negotiate competitive health insurance rates and benefits for your students.
You’ve worked relentlessly to educate them on how to use their insurance.
But then an upset student contacts you about an insurance claim they believe is inaccurate, or that they shouldn’t have received at all. It’s a difficult situation for everyone.
- Balance billing
The insurance company negotiates a discounted rate with in-network providers. The provider is not allowed to charge students the difference between the discounted rate and their standard rate, after the insurance pays their portion. When this happens, it is referred to as balance billing. Since out-of-network doctors do not have negotiations in place, they can (and will) balance bill. It is extremely important to emphasize the use of an in-network physician. - Upcoding
A student might receive a generic medication but be charged for a brand name. This is just one example of upcoding, when the code represents treatment for a more complex and expensive matter than the treatment they received. - Duplicate billing
It is when a patient is charged twice for a procedure they only received once. - Unbundling
Some treatments should fall under the treatment code but may be charged separately. The individual costs will be higher than the packaged cost. - Incorrect Patient Data
Insurance carriers compare the name, date of birth and insurance ID from the claim submitted by the insurance carrier to what is in their system. Any discrepancy can cause the claim to be denied sand a full bill to be sent to the patient. - Treatment/Diagnosis Discrepancy
When a claim is submitted to an insurance company, the treatment should match the diagnosis code. If it doesn’t, it’s likely the claim will be denied. - Coding Errors
Have you ever been charged for something at a restaurant that you never ordered or received? This can also happen with an insurance bill. On the bright side, this one might be simplest to catch. - Miscommunication
How much will that cost me? Although, when facing a health issue, cost may be the last thing on our minds. We may be tempted to ask this, especially in the case of a non-threatening situation. Doctor’s offices may give estimates before contacting the insurance company for a formal quote. Although at the end of the day, it is the patient’s responsibility to be aware of expected costs, if the doctor’s office gives bad information, a patient may be able to negotiate the bill for a lesser amount, or even have it completely written off.
If a patient is given an estimate before a procedure, they should check to see how long the rates will be honored. For example, some will only be honored for 30 days. If you receive treatment after the timeframe listed on the estimate, be sure to request another estimate to see how/if the cost has changed. If you receive treatment within the timeframe, make sure the bill you receive matches what was on the estimate. In some cases, a doctor’s office might increase their rate in-between the time you are given the estimate and try to charge you higher than what you were originally quoted. If this happens, go back to the doctor’s office and negotiate.
While some of these errors are easy to catch, others may take someone specialized in medical claims and coding to catch. No worries, we’ve got you covered. AHP provides Claims Advocates who can review and check the accuracy of bills for you and your students.