U.S. medical billing system (duplicate originals)

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills
User avatar
in_reality
Posts: 3722
Joined: Fri Jul 12, 2013 6:13 am

U.S. medical billing system (duplicate originals)

Postby in_reality » Sun Mar 19, 2017 2:12 am

How does medical billing generally work if you have more than one insurance policy? Can I easily get duplicate originals (diagnosis and receipt) from providers to get reimbursed? The cost of making a bill is covered in the insurance itself, so it's fine if I get billed for the extra paperwork. Just to be clear, I will pay providers by credit card and then seek reimbursement from multiple insurers (as allowed by their policies).

My understanding of U.S. insurers is that there is a coordination of benefits system where one policy is deemed primary and pays first and the second pays based on it's policy considering what the first payed. So I'm wondering if providers would refrain from issuing duplicate originals.

We're thinking of using several non-US policies (for a child we're sending to school in the US) and hence the question. There is no restriction on receiving compensation via multiple policies, so from the insurance company side it's fine (and actually necessary or we wouldn't be going through this trouble). Th e child will be somewhat covered via family coverage we get through work insurance, but we need additional coverage to satisfy school requirements.
[60% US _ 26% DEV _ 14% EM] | (-16% LC _ +8% MC _ +8% SC) | [47% FND/VAL _ 40% MKT _ 7% MOM _ 6% REIT] | (+/- 5% or *25% rebalancing bands)

Nowizard
Posts: 983
Joined: Tue Oct 23, 2007 5:33 pm

Re: U.S. medical billing system (duplicate originals)

Postby Nowizard » Sun Mar 19, 2017 12:16 pm

I cannot be certain since your policies are apparently held in another company, but your description of a primary and secondary payer is correct. Also, for those having insurance with American companies and who live here, the provider is required to file the insurance and bill for any amount not covered. That is the simplest way to pay since you would receive an EOB (Explanation of Benefits) from each insurance company that would list amounts billed, any deductions from the billed amount based on the provider's contract with the insurance company, and the amount remaining your responsibility. The provider must file your insurance if they accept it. If they are not on the panel of your insurance company and reject it, then you would be self-pay at full charge to the provider. Any reimbursement would then be between you and your insurance company.

You need to know two things: 1. Does the provider accept your policy, and 2. If your insurance is not accepted by a provider, will your insurance company reimburse you anyway.

Another possibility is if the person you are covering is a child attending an American college or university, they are very likely to offer a policy through that college or university. It would cover, and it could be beneficial to determine the cost and coverage of such a policy.

Tim

Mudpuppy
Posts: 4744
Joined: Sat Aug 27, 2011 2:26 am
Location: Sunny California

Re: U.S. medical billing system (duplicate originals)

Postby Mudpuppy » Sun Mar 19, 2017 3:29 pm

If I am reading this correctly, you're trying to avoid purchasing the university mandatory medical insurance for students. But your primary insurance does not meet the qualifications to avoid the mandatory university medical insurance, so you want to add a secondary policy for that child which would meet the qualifications. Is that correct?

If so, you need to make sure that your primary insurance and the secondary insurance you purchase will be accepted in the U.S.A., and that there are providers in the town where your child will attend college that accept BOTH insurance policies. If so, the provider will handle billing the insurance companies and your child would pay whatever co-pay is required at the time of visit (and be billed for the remainder after the insurance companies pay their part).

If your primary insurance has limited acceptance in the area of the university, I would echo Nowizard's recommendation to consider the university's mandatory medical insurance instead.

User avatar
in_reality
Posts: 3722
Joined: Fri Jul 12, 2013 6:13 am

Re: U.S. medical billing system (duplicate originals)

Postby in_reality » Sun Mar 19, 2017 6:57 pm

Thanks for your input.

Mudpuppy wrote:If I am reading this correctly, you're trying to avoid purchasing the university mandatory medical insurance for students. But your primary insurance does not meet the qualifications to avoid the mandatory university medical insurance, so you want to add a secondary policy for that child which would meet the qualifications. Is that correct?


Actually it's for high school, and the recommended (not mandatory) policies for international students won't cover US citizens (which our child is). So the options are 1) ACA coverage through the state exchange or 2) private insurance via a non-US insurance company. Or 3) register our child under their non-US citizenship but that seems fraught with peril.

The Non-US insurance is more expensive, but doesn't have a deductible so we'd prefer it. It's hard too see having less that $1400 in medical expenses over three years and that's the break even point.

Nowizard wrote:You need to know two things: 1. Does the provider accept your policy, and 2. If your insurance is not accepted by a provider, will your insurance company reimburse you anyway.


Our policy states it will reimburse us the expenses at any provider (assuming it's a covered service). Also, the school's MEDICAL CARE AUTHORIZATION FORM has several options a) get approval before care b) use in-network providers c) use any provider d) send the bill to you directly.

So we are expecting to pay all expenses and get reimbursed from the insurance companies (d above). The companies want original diagnosis and bills for payment though, thus the question about obtaining two copies.

***FWIW - we are fully covered for international travel by our work insurance, but it only pays according to our country of residences (low) reimbursement rate. Insurance companies offer overseas coverage, but it's different from our work insurer. Again, it's routine here to obtain coverage from more than one insurance company so it's certain they aren't going to be accusing us of fraud.
[60% US _ 26% DEV _ 14% EM] | (-16% LC _ +8% MC _ +8% SC) | [47% FND/VAL _ 40% MKT _ 7% MOM _ 6% REIT] | (+/- 5% or *25% rebalancing bands)

livesoft
Posts: 53223
Joined: Thu Mar 01, 2007 8:00 pm

Re: U.S. medical billing system (duplicate originals)

Postby livesoft » Sun Mar 19, 2017 7:15 pm

When I have had to deal with such things, I had my student directly talk to the school official enforcing their rules. It turned out that there so many exceptions that they did not make known, so that they would not be inundated with individual decision making. But if one did talk to them they were fair and always waived their general published requirements.

So have you discussed your issues with the enforcer? Maybe you don't extra insurance?
This signature message sponsored by sscritic: Learn to fish.

User avatar
in_reality
Posts: 3722
Joined: Fri Jul 12, 2013 6:13 am

Re: U.S. medical billing system (duplicate originals)

Postby in_reality » Sun Mar 19, 2017 8:00 pm

livesoft wrote:When I have had to deal with such things, I had my student directly talk to the school official enforcing their rules. It turned out that there so many exceptions that they did not make known, so that they would not be inundated with individual decision making. But if one did talk to them they were fair and always waived their general published requirements.

So have you discussed your issues with the enforcer? Maybe you don't extra insurance?


I guess that's a possibility - we're going that route for immunizations. Some things that are required in the US we don't even have here. [we will get them after arriving for certain though]

The reimbursement rates on the first policy are too low though.
The second policy has a cap on total reimbursement (which keeps the cost down).

If something extreme happens (like a brain tumor or cancer), the second policy covers flying him home where he can get treatment paid under the first policy which covers costs here.

So having two policies mean sometime we'd be reimbursed too much, but there is a risk too that both together won't cover things completely but we don't want to bring him home for treatment.

We're working on figuring out what exact documents the insurance companies will need, but the second policy requires the original diagnosis and bill for sure. Our current work insurance does too but will likely change soon (though is sure to have reimbursement overseas limited to local costs [much lower than the US for sure] for the procedure), so maybe a copy in the future would suffice.

If it's not possible to get duplicate bills, maybe we have to go with ACA or a beefier second foreign policy with higher limits to cover what we'd have to forgo in reimbursement from the first.
[60% US _ 26% DEV _ 14% EM] | (-16% LC _ +8% MC _ +8% SC) | [47% FND/VAL _ 40% MKT _ 7% MOM _ 6% REIT] | (+/- 5% or *25% rebalancing bands)

toofache32
Posts: 818
Joined: Sun Mar 04, 2012 6:30 pm

Re: U.S. medical billing system (duplicate originals)

Postby toofache32 » Sun Mar 19, 2017 8:34 pm

in_reality wrote:So we are expecting to pay all expenses and get reimbursed from the insurance companies (d above). The companies want original diagnosis and bills for payment though, thus the question about obtaining two copies.


in_reality wrote:We're working on figuring out what exact documents the insurance companies will need, but the second policy requires the original diagnosis and bill for sure. Our current work insurance does too but will likely change soon (though is sure to have reimbursement overseas limited to local costs [much lower than the US for sure] for the procedure), so maybe a copy in the future would suffice.


I'm confused...Are you just wanting copies of the bills? That's easy. This is called a "walkout statement" and you just ask the doctor's front desk staff for it. My office prints them out every day for patients who want to file for reimbursement through their insurance. It shows the diagnosis codes, CPT codes, and is also a receipt showing the patient has paid in full.

User avatar
ram
Posts: 755
Joined: Tue Jan 01, 2008 10:47 pm
Location: Midwest

Re: U.S. medical billing system (duplicate originals)

Postby ram » Sun Mar 19, 2017 8:57 pm

I am a physician working in US. Physicians in US are used to tolerating insurance hassles. Your requirements seem trivial. If you/your son call the physicians office and explain the situation I do not think you would have a problem.
If I were in your shoes I would pay for the good policy/ policies where your cost is $1400. (but pay attention to Livesoft's advice first)
Ram

User avatar
in_reality
Posts: 3722
Joined: Fri Jul 12, 2013 6:13 am

Re: U.S. medical billing system (duplicate originals)

Postby in_reality » Sun Mar 19, 2017 9:31 pm

toofache32 wrote:
in_reality wrote:So we are expecting to pay all expenses and get reimbursed from the insurance companies (d above). The companies want original diagnosis and bills for payment though, thus the question about obtaining two copies.


in_reality wrote:We're working on figuring out what exact documents the insurance companies will need, but the second policy requires the original diagnosis and bill for sure. Our current work insurance does too but will likely change soon (though is sure to have reimbursement overseas limited to local costs [much lower than the US for sure] for the procedure), so maybe a copy in the future would suffice.


I'm confused...Are you just wanting copies of the bills? That's easy. This is called a "walkout statement" and you just ask the doctor's front desk staff for it. My office prints them out every day for patients who want to file for reimbursement through their insurance. It shows the diagnosis codes, CPT codes, and is also a receipt showing the patient has paid in full.


Yeah, I guess that's all I need - a couple "walkout statements". I thought maybe since the US used a "coordination of benefits system" that they were reluctant to issue multiple statements.

ram wrote:I am a physician working in US. Physicians in US are used to tolerating insurance hassles. Your requirements seem trivial. If you/your son call the physicians office and explain the situation I do not think you would have a problem.
If I were in your shoes I would pay for the good policy/ policies where your cost is $1400. (but pay attention to Livesoft's advice first)


Thanks for the reassurance. Our child has neurological differences and we worry about things like skiing or zip lines and whatnot. Judo in gym class here made my wife neurotic (as injuries do occur) but anyway we signed off on any activities as being ok and need to be prepared come what may. I'm praying for the quick development of self-driving cars. He should be fine but if he needed to react quickly in an unexpected and unfamiliar way to save his life, he may or may not succeed.
[60% US _ 26% DEV _ 14% EM] | (-16% LC _ +8% MC _ +8% SC) | [47% FND/VAL _ 40% MKT _ 7% MOM _ 6% REIT] | (+/- 5% or *25% rebalancing bands)


Return to “Personal Finance (Not Investing)”

Who is online

Users browsing this forum: bluebolt, cockersx3, Da5id, FAST Enterprise [Crawler], hand, jimmyq, nolesrule, Silk McCue, Sophia1884 and 65 guests