The Specific Question

During medical emergency or urgent situations all we really want is proper medical and timely care. We assume that the hospital and doctors will do the right thing. That is to take our insurance and don’t overcharge us. Fortunately, it does happen that way most of the times. Then there are some times when we assume taking our insurance means they are participating in our insurance network. Unfortunately, that is often not the case. Taking our insurance simply means that the hospital or doctor will bill our insurance. If they get any payment it will be deducted from their total bill and send us the balance due.

If you are unsure the specific question to ask is exactly this: Are you a participating provider in my insurance network? To your surprise the answer to this question may be this “ I don’t participate in any insurance network.” So the next reasonable question will be: how much do you charge for this service? I am willing to bet that most doctors, and even hospitals will not give you an answer. They simply don’t know.

You want to ask: how can that be?
The answer is rather simple. In the case of a hospital the clinicians simply use an internal billing code, that is often not a code for the actual procedure; it is simply a computer system code that transfers into insurance procedure code a few days later in the computer software.
In the case of doctors, the billing company or office does the billing. The doctor may even know the actual codes and charges, but in most cases they will not disclose that information to the patient.
At this point the best one can do is getting a promise from the doctor that his or her changes are reasonable to our services.

Of course planned visits, such as office consultation, radiology services, or surgery can be financially pre arranged. It does take some work, and often putting a pressure on each party. A person need to get a CPT (procedure code), and diagnosis code from the doctor’s office. Then provide that to the insurance company and request the allowed payment amount from the insurance. Some will give it just for asking, while others have to be pressured to do so.

Insurance Payments to You

Why do medical insurance companies send you, the patient, the payments that should be going to the doctor? What are you supposed to do with these checks? is there a specific procedure that you are supposed to be following, that nobody every told you?

Here is what usually happens. You locate a doctor that you trust, and you have been going to them for awhile, and suddenly you start receiving insurance checks in the mail. You have no idea what is going on. Who do these checks belong to? Usually your insurance company will issue checks to you the patient, when the doctor is out of network, or doesn’t participate with your insurance plan. And, did you know that if there are several doctors in the group, that some can be participating and others can decide not to participate? So if you saw a doctor in that group who does not participate with your insurance, then you will receive the insurance check. So what are you supposed to do with this check?

I recommend that you cash the check. DO NOT HOLD ONTO IT! Make a copy of the check and then deposit it into your checking account.  Keep the copy of the check with your insurance explanation of benefit that came with the check. When you receive a bill from your doctor, send a personal check along with copies of the explanations of benefits and the copy of the check and send the exact dollar amount of that insurance check to the provider.  I do not recommend sending the check to the provider until they send you a statement so that your payments will be applied correctly to your account.

Do not make your doctor chase you down for that money as it was never yours to begin with. And do not pay the doctor less than the insurance paid you. You should NOT be making money off of your medical appointments.

Now suppose you receive a very large check, for thousands of dollars? Make copies of the entire document, including the check and then bring everything to your doctor’s office. Go to the billing department and endorse that check over to the practice. Have them give you a receipt for the check and keep that receipt stapled to your copies of the EOB and check. The sooner you bring your doctor the insurance checks, the happier they will be with you.