Do You Know What a Health Claim Is?

THE PROBLEM:

We’ve all received bills from our doctors and may have mailed them to our insurance company or third-party administrator (TPA) only to get a statement back indicating that the bill cannot be paid because it is a balance forward bill. “I don’t get it,” you say “why can’t they pay my bill?”

CONFUSED?

If you are confused about the claim or bill terminology, rest assured you’re not alone. Medical billing has its own unique language, just as any other industry does. Unfortunately this “language” makes it hard for us average Joe’s to understand. When discussing your bill with your insurance company/TPA or your medical provider’s billing staff, they may refer to your bill as a claim, bill, account balance, HCFA, 1500 or UB. “Whew,” you say, “what they heck are they talking about?”

BECOMING BETTER INFORMED:

Many people who have health coverage feel that just having coverage is all they need to do. “It’s my insurance company’s responsibility,” they say or the ever popular “My doctor is supposed to bill my insurance; it’s his problem, let him worry about it.” DON’T YOU BELIEVE IT! Your insurance policy is between you and your insurance company/TPA and are ultimately you’re responsible if the claims don’t pay, whether they were in fact denied or just didn’t reach the insurance company in the first place. So understanding the lingo, and medical bills falls into the lingo category, is to your advantage and will prevent you from experiencing unnecessary problems and frustration.

BILLS, CLAIMS – WHAT THE HECK ARE WE TALKING ABOUT?

There are several types of health claims (or bills) and they may be referred to by different names. The different names can make it complicated for patients to understand, especially when they receive repeated bills from their doctor or other medical provider. A health insurance claim, also called “claim,” “medical claim,” “standardized bill,” or “bill” is simply a statement of charges for services or treatment received from a medical or dental provider. Although most patients never see a standardized billing form, they may hear them mentioned when discussing their outstanding bills with their medical providers or insurance company/TPA.

LACK OF UNDERSTANDING:

Today, claims submitted to insurance companies/TPA are generally required to be on a standardized claim form. This is important to understand because medical/dental claims are processed using a unique coding system, which allows the claim to be processed more accurately and efficiently. Whether the claim is submitted to the insurance company/TPA on paper or in an electronic format, the end result is the same. The insurance company/TPAs computer system reads the demographic and provider information as well as the medical codes that indicate the diagnosis and the type of services received. Then the claim is processed according to your plan’s guidelines that are stored in the insurance company/TPA computer.

Because standardized claim forms contain all pertinent information that is necessary to process a claim and as a rule balance forward claims don’t provide the information needed, insurance companies/TPAs will often kickback a balance forward bill to the patient or deny the bill outright, using a code that indicates the reason they aren’t paying is because they received a balance forward bill.

THE TYPES OF BILLS:

BALANCE FORWARD BILL: This is the type of bill that most patients receive after a medical visit. A balance forward bill is a simply a statement sent to the patient from a provider’s billing office or collection agency that indicates an amount owed by the patient. These types of bills rarely include the detailed information necessary for the insurance company/TPA to process your claim, generally only listing a balance forward amount (which can include multiple dates of service and any accrued interest). The charge on the bill may encompass all of the unpaid charges in your account.

FORM 1500: This bill type used to be called a HCFA, and that name may still be used by some in the medical/insurance industry. Whether it’s called a 1500 or HCFA, this bill type is the standardized billing form that doctors, medical suppliers and other medical vendors use to submit their claims for payment. Dentists submit their charges on a similar billing form, called an ADA Dental Claim Form, which has verbiage specific to the dental industry. If a provider is contracted with an insurance company patients rarely see this type of bill. When providers are not contracted with the insurance company, and they require the patient to pay for treatment at time of service, patients may give them a 1500, so the patient can submit it to their insurance company/TPA. This way the patient can submit it to their insurance company/TPA in order to receive reimbursement for the payment they made to their medical provider at time of service.

UB-04 is another type of standardized billing form that medical facilities (hospitals, surgical facilities, etc.) use to submit charges to insurance companies/TPAs, for the services they provided to a patient. UB stands for universal billing form and the 04 indicates the year the form was created or updated (2004). This type of bill is seldom seen by patients and it looks quite a bit different than the 1500. When it’s discussed by people in the industry, this bill type is called a UB.

WHY DO I CARE? WHAT’S THE PAYOFF?

Possibly, and hopefully, less out-of-pocket expenses for you to deal with and maybe the ability to continue to retain the services of your doctor, because medical providers will not continue treating patients unless they receive payment. Patients (you perhaps) need to have a basic understanding of the types of claim forms that are out there, so that if it becomes necessary for you to intervene you will be able to provide the correct billing form to the insurance company/TPA. Understanding the lingo is another way to facilitate your medical/dental claim issues when you have to get involved. Although medical providers generally submit claim forms to the insurance companies/TPA for the treatment they provided to their patients, occasionally the forms don’t arrive where they were meant to go and this may happen for many reasons. When claims are not received by the insurance company/TPA, patients will continue to receive repeated, and sometimes threatening, bills from their providers and these are usually in the form of a balance forward bill. Sometimes patients need to intervene in the process to ensure a timely payment to their provider (or reimbursement to themselves) and prevent negative reporting to their credit. Before sending a bill to your insurance company/TPA, make sure first that it’s the right billing form in order to ensure the claim can be processed correctly and payments won’t be delayed. Copyright 2010



Source by Lynne Lucio

Granado Jane

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