Tag Archives: medical bills

Why Did my Health Insurance Deny My Claim!?

Posted on by The Simplee Team
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No! You expected your health insurance to cover a service, and then you get the dreaded letter that it’s been denied. Why do claims get denied and when does it actually matter (that’s right, sometimes it doesn’t matter)?

Your health plan might refuse to pay for a service or treatment you received for many reasons. It’s good to know whether it was denied because of the services themselves OR because of how your provider submitted it. Why is this important? Because in the first case, you’ll probably be responsible for paying the claim. In the second, you won’t be.

Here are some common reasons claims get denied where you could be responsible:

  • You didn’t get a referral or prior authorization when it was required
  • The service isn’t covered by your plan
  • You already used up your benefits for the service (like a cap on the number of physical therapy visits per year)
  • You went out of network when you have an HMO
  • Your insurance wasn’t effective at the time of the service

Don’t confuse these situations with those where a claim (or a portion of a claim) was denied because of how your provider submitted it to your insurance. This happens surprisingly frequently.  It might be that:

  • Your doctor didn’t submit the right billing code to your insurance plan
  • Your doctor didn’t submit the claim in the timeframe your insurance required
  • The service was actually covered as part of another claim or set of services
  • The claim is a duplicate that was already paid

You might see these things show up on your EoBs, or Explanation of Benefits–the statements you get from your health plan just informing you about your coverage (the ones that say “This is Not a Bill”). Just know that if your provider made a mistake submitting a claim, or your insurer found that it had already been paid for, you’re not responsible!

So before you panic, look into the reason for the denial. And if you believe you were billed unfairly for the cost, you can always appeal the decision. All health plans have to honor a process of reviewing claim appeals from their members. 

 

 

Saving Money with the FSA Grace Period

Posted on by The Simplee Team
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Did you miss out on spending down your FSA last year?

Hold on, all might not be lost. FSAs and HRAs are “Use it or lose it” accounts, meaning if you do not spend the funds by the end of your plan year, the money disappears.

But did you know that some employers have a grace period for FSA and HRA spending? Federal tax regulations allow them to extend the time for incurring expenses by 2 and ½ months into the new year. The extension is optional (not all employers have to offer it), but if you do have the opportunity, it’s a great way to make sure you don’t lose any of the money you’ve already set aside for medical expenses.

How do I know if I have a grace period?
Talk to your HR Department or benefits administrator. Remember, the grace period must be a benefit they have established in advance–it’s not a last minute change they can just throw in!

What if I don’t have any funds left in last year’s FSA or HRA?
If you’ve already spent down your 2012 FSA or HRA, the grace period doesn’t affect you. You’ll just continue spending your 2013 funds as usual.

If I have expenses for services I got in 2013 during the grace period, how will the money be deducted?
Employers will apply the expenses to your 2012 balance first, and then your 2013 balance (assuming you also elected an FSA or HRA for the current year).

What if I have an HSA?
The grace period doesn’t apply to HSAs because money in these accounts always rolls over year to year, so there’s no deadline to spend it.


Do you Need Supplemental Health Coverage?

Posted on by The Simplee Team
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With more and more people signing up for high deductible health plans, supplemental health policies have also become more popular. According to America’s Health Insurance Plans, high deductible health plan enrollment has grown by over 18% since 2011. Since these plans have deductibles of anywhere from $1,200 to $8,000, a supplemental policy to pad your plan can look very tempting.

Supplemental plans can either help pay your deductible and out-of-pocket costs, or they can pay out a lump sum of money either at one time or each day that you qualify for benefits.

The plans can be pretty inexpensive—as low as $12 a month for an individual and $20 to $30 a month for a family. But the benefits can vary drastically so make sure you know what you’re buying.

Considering supplemental health coverage? Ask these questions.

How much would an emergency would cost you?

Add up your deductible and the out-of-pocket you would owe for a few days in the hospital. Of course, you can’t be sure without knowing the actual costs, unless your plan has only fixed co-pays. But you can estimate: assume any major event would cost well over $10,000—how much would your co-insurance be?

Getting a rough idea will help you understand how useful a supplement might be.

Would you have other (non-medical) costs?

In an emergency, you might find yourself with other financial hardships such as lost wages, living expenses, or transportation costs. A supplemental policy can cover these expenses. Usually, the plan pays you a cash sum and you can decide how to spend it. One advantage of this type of policy is that it can help cover expenses that are not HSA-eligible.

What are the plan’s benefits?

Will the benefits cover enough of your likely costs to be worth it? A typical accident or injury plan may pay out $250 for each day you’re in the hospital, while a critical illness policy will pay a lump sum if you are diagnosed with cancer or have a stroke. If your day to day costs would far exceed the daily benefit, the policy is not worth the money.

How do you qualify for benefits?

It’s important to read the fine print here. A policy may only start paying benefits if an illness or injury reaches a certain degree of severity or may limit the days of benefits it pays. It may also pay much lower benefits for more common diseases—the times your most likely to need it. For example, one consumer was told his policy would pay $5,000 for cancer, but in reality, the $5,000 was only for internal cancer (breast or lung) and skin cancer was paid at $100.

The bottom line is, weigh the costs and benefits of supplemental health insurance carefully. If you have a typical health plan, you probably do not need an additional policy. But if you have a very skimpy or high deductible plan, you’re more likely to find a supplement to be helpful.

And most importantly, remember that these plans are meant to be what the name suggests—a supplement—and not a replacement for full health insurance.

 

Simplee’s Automatic Error Detection Saves Users Thousands of Dollars

Posted on by Simplee
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Have you had a chance to check out Simplee’s error detection feature yet?

We’ve been hearing from many users about how they’ve saved money or solved billing problems.

First, there was the user who told us he fixed a billing problem in ten minutes, after fighting his insurance company about it for the last four months.

Another user tweeted that he found an error that saved him $1,000.

And then, we interviewed another user who saved over $1,000 on several medical bills just by checking for errors. He said this didn’t even count another several thousand he saved by repeated calling out a separate error: His insurance company denying every claim because it believed he and his family had a second insurance plan that should be paying.

Using Simplee has made it easy for him to spot this error, plus additional ones such as duplicate claims or the incorrect insurance carrier being billed. He then uses Simplee’s notes feature to track the status of claims he’s disputing, so he knows not to pay them yet.

So far, he’s found that over 70% of the claims for himself, his wife, and two kids, contained some kind of problem that needed to be addressed before he paid the final bill.

To review your own account, log in to Simplee and look for our red, orange, and green flags next to a claim. These flags will tell you when we think we’ve spotted a problematic claim or a tip for saving money.

Do you have a success story about using Simplee? Let us know! Your tips could help other members save.

 

Tricks to time your health care to get the most out of your plan

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Just about every health plan has features that are tied to the calendar year: deductibles, annual benefit limits, and FSAs (Flexible Spending Accounts). And through just a bit of planning, you can save a lot of money on health care.

It’s all about timing. Try these tricks for getting the most out of your benefits.

Go on a deductible-spree:

Once you’ve met your deductible, it’s a good time to get any major, expensive services as well as other routine or elective care. That’s when your plan will pay out its full benefits. If you meet your deductible mid-year, try to plan any other health care services for that year. Waiting until the following year means you will have to pay the deductible all over again.

Watch benefit limits:

If you are getting repeating services – such as physical therapy, counseling, or chiropractic visits, don’t lose track of how many you’ve received. Many plans have an annual limit so stay within this number and know when the benefits roll over.

Get Free Dental Benefits:

Dental plans that offer free check-ups and cleanings usually use one of two methods to calculate your benefits: the calendar year or every 6 or 12 months. Find out what the rules are for your plan, and then pay attention—you know your dentist likes to send out reminder postcards and that Simplee will email you about unused benefits. Don’t ignore these!

Also keep in mind that some dental plans cover procedures up to a dollar maximum for the year. If you are close to reaching the max near the end of the year, but still need a root canal, you might want to wait until the next year for better coverage.

Spend down your FSA: Flexible Spending Accounts are use-it-or-lose it at the end of the year. Most turn over at the calendar year, but some plans use a fiscal or academic year. Make sure you know the date your plan renews, and spend down your account in time. If you find yourself with a large balance near the end of the year, you can always stock up on staples such as bandages or contact solution.

Do you have more tricks that you’ve used to squeeze the most out of your plan? Share with us!

 

Simplee Now Automatically Screens Your Claims for Billing Errors

Posted on by Simplee
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Are you ready for an exciting new feature?

We know how painful it is to read through medical bills to make sure you were charged the right amount for the right services. And how even more painful it can be to not read through them and just pay what’s on the bottom line (hoping that you’re not getting screwed).

We’ve been thinking about ways to make it easier to understand your bills—and we came up with a feature that automatically reviews your EoBs (Explanation of Benefits) for some of the most common billing errors, reasons insurance didn’t cover a claim fully, and even strategies for how to save money in the future.

Now, when you get an email from Simplee about a new claim, it will include color-coded flags next to claims where we have identified a potential problem. Click on the claim, and we’ll explain the problem and what you should do next.

We’ve seen an average savings of about $91 on claims that the feature has flagged. Although one user who spotted a billing error through Simplee saved almost $1,000. Our hope is that this new feature will encourage everyone to start looking more critically at their claims and benefits and find ways to put more money back in their pockets.

Studies have found anywhere from 40%-80% of medical bills containing an error, so it’s worth taking a second look, right?

Some of the issues that Simplee will scan for include out-of-network claims, benefit limitations, claims for services that were previously covered, prescription drug costs, and a lot more. Learn more.

What billing errors have you noticed in your EoBs? Let us know at support@Simplee.com so we can start spotting them for you.

Error flag email
Here’s what you’ll see in your email. Keep your eyes out for it!

 

Questions to Ask When… You First Get a Medical Bill

Posted on by Simplee
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You get a medical bill in the mail, or a notification that there’s a new claim in your Simplee account. Now what? Here are the questions you should be asking.

1) What were you charged for?

It seems obvious, but make sure you were charged for the right services and procedures—and that you were not charged for services that may have been ordered, but then cancelled. If the bill doesn’t clearly list the services, ask for an itemized bill. And if there are items you don’t understand, ask the provider to explain. If you want to be an extra rock star at checking bills, look up the CPT codes to make sure they match the service you received. The codes are not always shown on a bill, so you may have to request them from your provider.

2) What are the dates of service?

Are the dates correct? This is especially important for hospital stays. Most hospitals do not bill you for the day you were discharged if you left in the morning. For smaller services, such as lab tests, you may see a date sometime following the visit where they were ordered.

3) Who paid what?

The bill should break down the cost of the claim into at least three figures: the total charge or fee, any discounts or adjustments, and the amount your insurance covers. Your attention should be on the cost after any discounts and the portion your insurance covered.

4) Does “who paid what” line up with my benefits?

This is where you either need to pull out your benefits documents, call your insurance company, or log in to your Simplee account. Find out:

     • Have you have met your deductible? (the Simplee dashboard will show you)

     • Was the provider in or out-of-network?

     • Were the right co-pays or co-insurance applied?

     • Was there something that should be covered but was not?

If you’ve asked all these questions and you’re still wondering if the bill is correct, it might be time to call the plan or a professional billing advocate.

Medical Bills you Shouldn’t Pay: The Story of Balance Billing

Posted on by Simplee
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Think back to that big hospital bill you got when you thought the stay would be covered—even when you made sure the medical center was in your network. Or the outpatient surgery, where there was a huge fee, even though the surgeon said he takes your insurance.

You might have been balanced billed.

In two sentences, balance billing happens when your insurance company and your doctor don’t have an agreement on how much a service should cost. And when the doctor doesn’t think he or she has been paid fairly, you get billed for the difference.

But what’s important is that often times, you are not responsible for the bill. In many states, balance billing in certain situations is against the law.

What is Balance Billing?

Balance billing can occur when you visit a non-contracted (or out-of-network) provider. That provider has no agreement with your insurance company as far as how much he or she should be paid to treat you (most likely, they couldn’t agree on what should be paid, that’s precisely why there’s no contract). That’s why balance billing is most common with HMOs (and sometimes PPOs).

Here’s what happens, in a nutshell:

1) You get care from the provider, and he sends a claim to your insurance plan.

2) The insurance plan doesn’t pay the entire amount (why would they? They’ve made no agreements to).

3) The provider is unhappy. He didn’t get fully paid for his services, after all.

4) The provider bills you for the difference.

Of course, it’s more complicated than this. Knowing whether or not your providers were in-network is not always obvious. And separating balance billing from deductibles and co-insurance (which are legitimate charges) can be confusing.

Remember that providers could include many types of people or facilities: Every doctor that sees you in the ER, the imaging center where you got an MRI, the ambulance company, or the hospital. For example, many balance billing cases occur when an anesthesiologist is non-contracted, even though the surgeon and the hospital are in your network. You hardly get to see the anesthesiologist, let alone ask ahead of time whether he or she works with your plan. The same thing happens in the ER. Most people aren’t about to stop to ask about insurance in the middle of an emergency.

 

What If You Think You Have a Balance Bill?

1)   Request an itemized bill if the services are not already broken out in detail. There should be separate line items for each provider.

2)   Compare the charges to your network benefits. Have you met your deductible? What are the co-pays or coinsurance? Determine whether the charges exceed your usual cost-sharing.

3)   Call your health plan and ask whether every provider involved was a network provider.

4)   Find out what the rules on balance billing are where you live—every state is different. Contact your state’s Insurance Department or go here for a quick check.

5)   If you believe you’ve been sent a balance bill when it was not allowed, contact your provider. If you can’t get the bill dropped, think about getting help from your state Insurance Department or a billing advocate.

Never ignore a bill—that could end up affecting your credit—but don’t be shy to question the amount that you owe. To learn more about why out-of-network care can cost so much, see Going Out of Network? Read This First.

 

 

Avoiding Big Bills in a Medical Emergency

Posted on by Simplee
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No one really wants to be thinking about health plan rules in the middle of a family emergency. But then again, no one’s ever excited to receive a big unexpected bill for a trip to the ER—especially when it could have been avoided.

The key is to be prepared with knowledge about your health plan before you need it. So if an emergency does come up, you’ll know what to do:

Decide if you really need the emergency room.

Up to 25% of visits made to the ER are not actually emergencies—they are cases of allergies, coughs, or sprains and strains, which could have been treated in the doctor’s office. Yet when treated in the emergency department, the same care can cost three to four times more. There is also no guarantee you’ll get faster or better service in the ER. Depending on how busy they are, and how urgent your condition is, the average ER wait time can be up to four hours.

Call your plan’s nurse advice line.

Most plans offer this service for free, 24 hours a day. Not sure or want a second opinion? Call back. The benefit is yours, and you’ve paid for it.

Try an urgent care clinic.

 If your condition is not life threatening but also can’t wait for your regular doctor, this might be a good option. While most clinics are not open 24 hours, the costs will be a fourth or a fifth of what an ER would charge. Also be aware that health plans have varying rules on how they cover urgent care visits, so find out before you go.

 

If you do need to go to the emergency room:

Avoid the ambulance.

Unless the situation is life-threatening, or a person has a neck or spine injury, you may get care just as quickly in your own car. Ambulance fees can be high, and some plans will not cover them if the situation was not actually an emergency. What defines as an emergency can be tricky. According to federal regulations, an emergency is what a “prudent layperson” would determine to be a situation requiring emergency attention. But insurance companies don’t always have the same opinion as Joe on the street, and may refuse to pay a claim. This kind of denial can be appealed, but can be difficult to win. So if the urgency of the situation is unclear, but driving on your own is definitely safe, avoid the ambulance altogether.

Learn your authorization rules.

Some plans require you to notify them before you go to the ER. Others may require that you obtain authorization from your primary care provider first. Under the health reform bill, newer plans can no longer require prior authorization, but plans that were created before the bill was passed in March 2012 (grandfathered plans) are exempt from this rule.

Question your bill.

Start by asking the hospital for an itemized bill. Go over each of the expenses to see if they look right—for example multiple charges for the same thing, services that never happened, or incorrect diagnoses. Since ERs can be chaotic places, with multiple physicians handling one patient, it is not uncommon for a diagnosis to be changed or recorded incorrectly, or for a test to be ordered but never completed. Be aggressive in asking the hospital about charges that don’t make sense or appealing to the health plan if they refuse to cover certain services.

Beware of balance billing.

Most plans are now required by the health reform bill to cover emergency care at the same cost shares for you, whether the hospital was in-network or out-of-network (grandfathered plans are exempt). But in situations where a plan does not have a contract with individual physicians staffing the ER, the plan might reimburse physicians at lower rates than the doctors normally charge. So the physicians then turn around and bill their patients the difference—a practice known as balance billing. Each state has different laws around balance billing when it comes to in-network versus out-of-network providers and HMOs versus PPOs. Find out what the laws are in your state to make sure you are not being improperly billed.

Remember, Simplee does not give medical advice – only financial. If you are unsure about the urgency of your medical situation, always be sure to seek the care you need.

 

How to Spot Medical Billing Errors in 5 Minutes

Posted on by Simplee
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Most of us have received a medical bill with an error on it at some point in our lifetime. It’s bound to happen with an estimated 50 to 80% of bills containing some kind of mistake. But how many of us have actually bothered to look for errors, let alone succeed in finding one? 

It’s not easy. Medical bills can be pretty complex for a single sheet of paper. So most of us just grumble at the high cost, write our checks begrudgingly, and then move on with our day. We never quite know whether what we paid was truly right or not.

 But how do you actually detect an error? What should you look for?

This stuff can be complicated, and some errors require an expert’s eye. But others only take a few minutes to spot. Really. Try these quick tips each time you get a new bill. 

  • Find the discount. If you’ve met your deductible, your health plan should be paying. It’s that simple. If you find you’re being billed for the full charge, there is probably something wrong.
  • Double check dates of service. This is especially important for hospital stays. Sometimes patients are billed for more days than they actually spent in the hospital.
  • Look for duplicate charges. If the same service name or CPT code appears twice on a bill or you get more than one bill for what appears to be the exact same service, you might be getting charged twice.
  • Check the network discount. If your plan has co-insurance (you pay a certain percent of the cost), you usually have to pay a higher percent for out-of-network providers than in-network. Look for the discounted or adjusted rate on your bill and then check what percent your insurance company applied. Sometimes the out-of-network discount is applied when the provider was actually in-network, which could make you responsible for 50% of the cost rather than 80%.
  • Compare past bills. If you got similar services from the same provider in the past, you might be able to spot an outlier. Simplee allows you to compare bills at a glance, without having to save and sort through a pile of paper. One man saved over $900 when he noticed one bill where the wrong discount was applied.
  • Look-up the CPT code. This is a five digit code—usually all numbers, but sometimes four numbers with a letter on the end. There is a code for every procedure you could get—for example one for a routine physical, one for a flu shot, one for an x-ray of the abdomen, etc. Make sure that the description of the code matches the service you received. If the description sounds inaccurate or more elaborate, that’s a red flag.

By being familiar with your health plan’s rules and regularly reviewing your bills, you’ll get more comfortable with how they look and what seems off. But most people don’t receive bills frequently enough to get that much experience.

If you are unsure, call the plan or try contacting your state’s Department of Insurance, or the agency that regulates health plans. They may offer free consumer assistance with bills. And if you’re still in doubt? Consider a billing advocacy organization such as Medical Billing Advocates of America.