There are many elements to even the most routine of medical office visits that can create errors. From how the medical provider bills to how the insurance carrier pays.

If you do not have insurance, making certain that the billing is accurate is an addtitional concern for many so that they pay only the fair and appropriate fees.

The knowledge of bills from hospitals is enormous. It takes professionals that work with these bills every day a great deal of time and experience to master. The average healthcare consumer is at a great disadvantage if they do not possess this extensive understanding of the complexities of hospital bills. This is true for both Outpatient and Inpatient services.

Diagnostics include a wide range of services from laboratory testing to radiology and more. There are many factors that create the potential for error including medical nesessity, bundled services, authorization, coverage limitations, and more. 

The charges for transportation can range from emergency response to routine medical transport to and from medical treatment appointments. This is, again, a complex knowledge base that most consumers simply lack experience in or knowledge of the sources of guidelines on.

There are many services that create additional challenges ranging from various therapy and counseling to additional billable or allowable services rendered at the same time as the services listed above. Be sure that you are only paying for those services that you are responsible for paying for and at the correct billable rate.

HMO, PPO, POS, ACO, and the list in the alphabet soup goes on. Each coverage type has its unique structure and each insurance carrier its own terms and conditions for each coverage type.

Each insurance plan develops its unique benefits and terms of coverage. Even within the same insurance, coverage can vary by plan type, group, and other factors. This can understandably be overwhelming for the consumer.

A surgery such as a “nose job”  or “breast reconstruction” may be covered or it may not be, depending on the circumstances. Cosmetic or restorative? Emergency or elective? It requires vast knowledge of the complex rules to reach a conclusion on appropriateness of billed charges as well as insurance payment accuracy.

“But I used an In Network Provider”

This is a common exclamation. There are a number of root causes for errors. Insurance carriers records can be wrong. The provider ID may be mismatched. A related provider that bills separately may not be In Network (very common in Emergency Room visits).

Sorting this out efficiently takes knowledge of the many possibilities to arrive at the correct outcome.

There are thousands upon thousands of different services that could possibly be billed for. Therapeutic or Exploratory? Screening or Diagnostic? Treatment or Prophylactic? Utilization Limits and the list goes on. It takes significant experience to navigate the complexities of types and classifcations of these services and the result can mean payment or non-payment of a bill.