Insurance companies have established networks in most major cities. These networks consist of physicians, hospitals and ancillary providers who sign a contract to accept the “reasonable” amount as payment in full for a given service. Every insurance company has its own definition of reasonable, so the contracted amount may vary considerably from insurer to insurer.
Services are provided and claims that contain procedure and diagnosis codes are automatically generated and filed electronically with your insurance company. Each procedure code is paid according to the amount agreed upon in the provider’s contract with your insurer.
Say, for example, an office visit coded 99213 could normally be billed at $100 by your doctor, but the reasonable amount determined in the provider’s contract with your insurance company is $50. If you chose an in-network provider and your policy covers 80 percent of the visit, your insurance company would pay $40 of the reasonable charge amount, and you would owe the $10 difference (assuming you have already met your deductible). The in-network provider must write off the remaining $50 that it would otherwise charge for the service you received.
Understanding this process can be a big help as you examine the itemized bills you receive from your provider and the Explanation of Benefits sent by your insurance company. But finding mistakes can still be tricky.
Mistakes made by a provider’s office may include bills for incorrect services or even for procedures that were never performed. The insurance company, on the other hand, may incorrectly determine that a procedure is not covered or not medically necessary, or it may say a service provider is not in-network, when in fact you’ve been told by the provider they are! Another common mistake is that an in-network provider but doesn’t write off the disallowed amount and instead bills you for the difference!
ClaimMedic has the experience and expertise to organize, analyze and verify all of your medical bills, so you avoid these types of mistakes and enjoy the peace of mind of knowing you’re not paying medical bills you don’t owe.