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WHY DOESN’T MY DOCTOR KNOW WHAT MY INSURANCE COVERS? You go out of your way to ensure that any doctor you see is in your network.


You pay your copay before you even see the doctor. Why, then, do you end up receiving bills that you weren’t expecting for services not covered by your insurance? Case Studies. Regardless of what might happen to the Affordable Care Act once the new administration takes office in January, what appears most certain to continue is that all of us must become more responsible for the financial side of our healthcare.

Case Studies

This means that we are now in a world that requires that we know what we don’t know, and if we aren’t up to the task of learning the ins and outs of the insurance maze, we’ll need to find the assistance of someone who does to ensure that we aren’t paying for inflated or unnecessary medical bills. Here are a few suggestions on how to minimize your risks for unexpected medical bills: This includes: This is the time to review copays, deductibles, coinsurances, and non-covered expenses. Medical Bill Review, Basic Watchdog Subscription Services, Medical Claims Concierge. The health insurance claims process continues to change.

Medical Bill Review, Basic Watchdog Subscription Services, Medical Claims Concierge

Now more than ever, it is critical to be pro-active in understanding and managing your health insurance claims. Assumptions can be dangerous and can lead to unexpected and compromising financial consequences. Subscribing to our Watchdog Subscription Services is the first step towards medical expense literacy and empowerment. Your yearly subscription includes the following services: Coaching/Consulting Services: No question is too big or too small. EOB/Bill Review: We review your explanations of benefits and medical bills to ensure that the services have been billed correctly, that the claims have been processed completely, and that you haven’t been billed for services in error. Prescription Costs: We help locate lower-cost alternatives for medication fulfillment.

How Does Medicare Cover Hospital Stays? Medicare coverage for hospital stays can be confusing.

How Does Medicare Cover Hospital Stays?

In order to understand what costs you might be responsible for, you need to understand a number of administrative factors. 1. In-patient vs. Out-patient. Get Meducated — Why Doesn’t My Doctor Know What My Insurance... Medical Bill Dispute Assistance. CASE STUDY: COORDINATION OF BENEFITS PROBLEMS. Situation.


Get Meducated: Copays For Quality Of Care. Copays, once simple and straight forward, are now becoming more complex.

Get Meducated: Copays For Quality Of Care

Not only are there different copays for different places of service and service providers (office visits vs emergency room visits; specialist vs primary care), but recently more insurance companies have instituted gradations of copays tied to quality assessments of physicians in their networks. Typically these quality designations are based not only on the quality of their clinical care, but also on the cost of that care to the insurance company. In order to incentivize their members to utilize the quality providers in their network, insurers are either removing the patient’s responsibility for the copay entirely or reducing the cost of that copay if members use one of the quality physicians in the network. Medical Billing 101: Levels Of Service – Get Meducated – Medium. Get-MEDucated with Systemedic -10 Deadly Assumptions In Light Of The …

In-Hospital vs Outside Facilty Testing. Situation A 58 year old woman with a family history of ovarian cancer, undergoes yearly transvaginal ultrasounds as one means for early disease detection.

In-Hospital vs Outside Facilty Testing

These sonograms were always performed at a radiology facility not associated with a hospital. A previous sonogram detected growths of undetermined cause on one ovary, which prompted her gynecologist to request a repeat of the sonogram. Given her concern, she requested that the sonogram be performed at the hospital by one of her colleagues, someone whose judgment she knew and trusted. Because the patient had a high deductible plan, she wanted to know in advance what her financial responsibility might be. Given this confirmation, the patient followed her doctor’s request and scheduled and had the procedure at the hospital. Copays Are not Just For Office Visits Anymore. Almost everyone is now familiar with copays.

Copays Are not Just For Office Visits Anymore

These are the flat fee charges that insurance companies require that patients pay each time they have a visit a doctor. When copays were first instituted, they applied only when a patient actually saw a doctor. Emergency Delivery Can Have Its Cost. A 32 year old woman was pregnant.

Emergency Delivery Can Have Its Cost

She had insurance coverage through her husband’s employer. She received all of her prenatal care through in-network doctors and facilities. All of the prenatal claims were submitted to her husband’s insurance and paid by them. She was scheduled to deliver at an in-network hospital when she encountered an issue that required that she deliver immediately, 4 weeks before her planned delivery date. Health Savings Accounts Can Cushion The Blow Of Medical Bills. 3 Steps to Avoid Medical Bill Problems by Get Meducated. What To Do When Treatments Are Denied. A 47 year old man suffering from rheumatoid arthritis for more than 15 years, was denied authorization by his new insurance company for an infusion therapy that had been authorized by a previous insurer, and from which he received considerable relief from pain.

What To Do When Treatments Are Denied

The patient’s attempts to resolve the issue through the ordering physician were ineffective given a number of administrative deficiencies at the practice. Systemedic needed to unravel the course of events that led up to the authorization denial. This involved numerous conversations with the rheumatologist’s office to secure the chronology of events and the medical records supporting the need for the infusions.

STUDY MEDICAL BILLS CAREFULLY…80% HAVE ERRORS. A 25 year-old female with persistent nasal congestion, sinus pressure, and sore throat that had not responded to numerous treatments prescribed by her primary care doctor In a phone call to her doctor, the patient was instructed to return to the office that day to see an ENT (Ears/Nose/Throat) Specialist in the same medical practice. During this visit, the ENT examined the patient and performed a procedure that involved placing a scope in her nose to view the nasal and sinus passages. She was given two prescriptions to treat the condition.

The patient paid her copay and left. Approximately 3 weeks after the visit, the patient received a bill for $205.66 from the ENT. Need An X-Ray? Think Twice Before Going To A Hospital. You need an x-ray. If you are like most people, your knee-jerk reaction would be to go to the radiology department of your local hospital for the procedure…and that decision could cost you more money than necessary. Here’s why. Insurance companies pay doctors and facilities through negotiated contract rates. The larger the organization, the greater their bargaining power and therefore, the higher their contracted rates for the services they provide.

If you need an x-ray or other radiological procedure, the costs for any given procedure will vary by facility. When Your Doctor Says There Is A Problem With Your Insurance, Be Careful Of The Charges. Insurance companies are continually updating their systems to confirm coverage for their subscribers. They are looking to see if there is any reason that a patient might be covered by another insurer. Their goal….to avoid making payments for services that should have been covered and paid by another insurance company. It is in everyone’s best interests that confirmation of active coverage happens no later than the time at which the services are provided. However, sometimes, unbeknownst to the patient, policies are terminated retroactive to an earlier date. Systemedic - Health Insurance Basics. BE SURE TO WAIT FOR AUTHORIZATIONS. Situation A 23 year old woman suffered from a variety of symptoms, including extreme fatigue, dizziness, and joint pain, symptoms that increased in type and frequency and grew to include headaches, memory loss, difficulties concentrating, hair loss, facial and extremity numbness, blurry vision, and chest pain over the course of 2 years.

Attempting to find a cause and treatment for her symptoms, the patient consulted a number of physicians from internists to rheumatologists and infectious disease specialists. A multitude of blood tests were conducted with no diagnosis. She was treated for Lyme Disease twice, but the symptoms continued. Minimize Your Medical Expenses with Systemedic. It’s 2014 and the Affordable Care Act is in full force. How To Make A High-Deductible Health Plan Work For You. How To Confirm In/Out Of Network Providers/Facilities. Employee Insurance Bill Claim Assistance & Benefits Program. The Low-Down On Vaccine Coverage. The Medicare Part B Deductible. Strategic Partners. Given the breadth and complexities of the healthcare industry, we have aligned with experts in the field who can address other aspects of healthcare beyond our focus.

How A Doctor Gets Paid Impacts Your Bottom Line. Medical claims consist of two key pieces: procedure codes and diagnosis codes. Determining Network Coverage Can Be Tricky. It should be fairly simple to determine if a provider is in network or not, right? 10 Deadly Assumptions In Light Of The Affordable Care Act. 3 Steps to Avoid Medical Bill Problems. The 911 On Emergency Room Visits. 1. Prescription Drug Cost Comparison.

Health Insurance Basics. Medical Claims Advocate Helps Reduce Medical Bill Costs. What is a medical billing advocate and why do I need one? Medical Billing Solutions Company. Medical Bill Dispute Assistance. Health Insurance Coverage Issues. Medical Billing Advocate.