Insurance & Your Bill

What billing or insurance information will I receive?

If you are covered by insurance or Medicare, you will receive an Explanation of Benefits from the company. You will not receive a statement from the hospital until we have heard from your insurance company. That statement should agree with the information you received from the insurance company. In order to assure that this insurance information is accurate, it is very important that you provide us with updated insurance information. If you do not have insurance, you should receive a statement within 30 days of your services.

How long will it take to get things settled with the insurance company?

The length of time for claims to be processed by an insurance company can vary. One of the primary considerations is when does the hospital submit the claim. It can take anywhere from 7 days to a month for the hospital to send the claim to your insurance, depending on the type of services provided and physician documentation. Once the claim has been submitted, most insurance companies process payment within 2-4 weeks. However, claims involving liability questions or the need for additional documentation may take longer. If you are covered by more than one health insurance policy, the claim to the second insurer cannot be sent until the primary payer has finished correctly processing the claim. It is also important that, if you receive any correspondence from your insurance company asking for additional information, you respond quickly, as the claim will be held until your answer is received.

I have Medicare and a supplement. Why am I still getting a bill from the hospital?

Medicare is designed to cover a broad spectrum of services for Medicare beneficiaries. However, by federal statute, there are certain services and items that are not covered. The most common of these is self-administered drugs. When you are an outpatient (in the specialty clinic, outpatient surgery, the emergency room or observation), Medicare prohibits us from billing Medicare for any drug that can be self-administered by the majority of patients. This would include tablets, liquids, salves and creams, and inhaled medication. It also includes insulin. With the exception of insulin, it does not matter whether the individual patient is capable of administering the medicine, only that the medicine be classified as self-administered. Insulin will be covered in a case where a patient is in a diabetic coma. Other instances where you may receive a bill after Medicare and your supplement has processed a claim is when the hospital informed you prior to the service that we felt that the particular service does not meet Medicare’s Medical Necessity Rules or their frequency guidelines. In these cases, we would require you to sign an Advanced Beneficiary Notice (ABN) prior to the service, either refusing the service or acknowledging that you will be responsible for the cost.

I think you submitted my claim incorrectly. My insurance pays for an annual physical and you show that the company denied the claim.

Under the rules of the Patient Protection and Affordable Care Act (PPACA), many insurance companies do cover the cost of an annual wellness exam. However, it is important to know what this wellness exam is not. The rules apply to visits for “symptom-free and disease-free individuals”. Conditions which require additional evaluation or treatment are not considered preventative in nature. If you require an additional evaluation or treatment, an appropriate office visit charge will also be submitted to your insurance company. If you, with the recommendation of your healthcare care provider, decide to have lab work performed, your insurance company will receive a separate claim for all the lab work done. These services may or may not be covered by your insurance company. Be advised that “screening’ is designed for a person who has not yet been diagnosed with a particular disease. For example, your insurance company may allow for lipid screenings on an annual basis to determine if you have high cholesterol. If it is determined that you do have hyperlipidemia, you may not be screened for it any longer. Your provider will order periodic tests to monitor your condition to check the efficacy of your medication, diet, and exercise program, but once you have the disease, you may no longer be eligible for free screenings. By the same token, your provider may decide to order a screening lab test, such as potassium, that, while it is screening, is not 100% covered by your plan. Just because a test is ordered as a result of an annual wellness exam does not guarantee that the screening is a free preventive service covered by the PPACA. It is also possible that you presented to the office requesting a physical required by your employer or for a DOT physical. If the intent of the office visit is to have a work physical, health insurance companies will frequently deny coverage for the visit. If a patient presents for an annual wellness visit and asks for an employment physical form to be completed at the end of the visit, it will be up to the provider to determine if the annual wellness visit covers everything required by the employment physical. If the employment physical requires additional assessment, the visit will be considered an employment physical and not an annual wellness exam. This is always true with a DOT physical.

I have coverage through the VA and/or ChampVA. Why do I still still owe something for my visit?

There are times that the VA and/or ChampVA will require the patient cover some or all of the cost of services. For example, if services are provided in the emergency room and the VA determines that the patient could have safely sought treatment at the Emergency Department of a VA hospital, the VA will not cover the visit. Neither will the VA cover outpatient services that have not been preapproved by the VA. ChampVA often has a coinsurance/copay required for certain outpatient services.