Way too often, I get calls about bills that Medicare Members don’t think they owe. Confused and frustrated, Medicare Beneficiaries often just pay the bill. Without the understanding of the EOB (explanation of benefits), you will continue to pay bills in the dark. If you have a Medicare Advantage plan, your plan is illustrated in a Summary of Benefits that you should have received when you signed up for the plan. This summary guides you in point-of-service charges.
But it is the EOB summaries from your health insurance company that are key to tracking medical spending and uncovering billing errors. I’ve outlined a step-by-step process to empower you to easily reconcile your claims. In the event your efforts do not succeed, reach out to your Medicare agent. At Bayside Benefits, we assist our clients as a courtesy and have saved our clients hundreds of dollars and hours of aggravation.
1- Review Your EOB – First confirm how much you owe from the EOB (Explanation of Benefits). Your insurance company is the authority on their contract with their doctors and hospitals. It’s an important part of having a network.
2 – Review Your Bill – Use the EOB to confirm your copays by matching it to the bill. Remember you may have already paid it at the point-of-service. This is an important step in finding errors as well! If a service is not covered or was not paid, there will be a note included. This is where we often see that a bill was never sent to your insurance carrier or the billing code for a procedure was entered incorrectly.
3 – When The Bill Doesn’t Match – If they do not match, call the doctor/hospital and let them know that you have an EOB that states a different amount. Be sure to read any notes on the EOB to the billing department. They should be able to investigate on their end and correct the bill immediately. If there is money owed to you, doctors will often credit your account for your upcoming visit.
4 – Billing Department Doesn’t Resolve Bill – If the doctor still disputes the EOB, call the insurance company’s claims department. The carrier has a vested interest in getting this rectified. You are their Member and doctors have entered contracts for approved amounts on medical services. Explain you have an EOB, you contacted the doctor, and you request they reach out to the doctor to resolve the issue. Often insurance companies will put you on hold while they resolve the issue.
5 – Balance Billing – In 2016, Florida passed a law for No Balance Billing. When patients at in-network facilities receive services from non-network doctors, patients cannot be billed for the out-of-network services. Rather billing is to be at in-network costs. Some Ambulance services are exempt.
6 – Medicare-Medicaid – It is generally illegal to bill if you use a doctor that accepts the Medicare assignment or when you have Medicaid and your doctor has an agreement with Medicaid.
7 – Pharmacy – The Federal program, Extra Help, follows you on any insurance plan you select. Insurance companies “load” your set price into their system. Ask for a supervisor at the point of sale if the price differs.
Finally, while Congress debates a universal bill, Florida has pass a No Balance Billing Law in 2017. That goes for HMO’s and PPO’s. Out of Network providers working in hospitals cannot send a balanced bill to any resident of Florida. Wishing you ease in reconciling your Medicare claims.