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Allowed Amount – Medical Billing Terminology

Hello and welcome to another issue of my blog!¬† Just as a reminder I have 4 kinds of blogs and you can find out all about them at the bottom of this post. ūüôā

This post is for my medical billing series.  Whether you are in the medical industry or not, this post IS FOR YOU!!  Everyone visits doctors Рeither because they are sick are trying to prevent sickness.  Either way, this series is to help you understand the crazy world of medical billing.  I will be posting on everything from billing terminology to crazy diagnosis codes.

img_5317Today, I am discussing something that many people do not understand РAllowed Amount.  What does this mean?

If you read my post, How to Read Your Medical Bills – Is it Even a Bill? then you may already understand what this means.¬† (And if you haven’t read it, you should grab a cup of tea – or coffee if you aren’t allergic to the bean like me,‚ėĻ find a comfy spot and read it.)

However, whether you have read it or not, I Continue reading

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How to Read Your Medical Bills – Is it Even a Bill?

Ok… so first things first.

What I mean by “medical bills” in the title is literally just that.¬† It is a “BILL” sent to you for a balance that the sender is claiming that you “OWE” them.

The reason I feel led to be so specific is that often times an insurance company will send correspondence to one of their members and it appears to be a bill when it isn’t a bill at all.¬† In fact, most of the time it will be what is called an EOB (Explanation of Benefits).

First, let’s talk a little about EOB’s.

An EOB is simply what it stands for – an explanation of the benefits the insurance company provided to the Patient and Guarantor.¬† Depending on the insurance company, EOB’s can contain various information. It can contain some or all of the following things:

  • Patient Information – This is the person that received¬†the medical services.¬† It can include the patient’s name, address, date of birth and insurance ID/Group number.
  • Guarantor Information – This is the name of the person that is the owner of the insurance policy.¬† It can include the same type of information as the patient.
    Example #1: Jane Doe is seen at the doctor.  Her husband John Doe works for ABC company and has an insurance policy for himself and his wife Jane.  The EOB would list Jane as the Patient and John as the Guarantor because he owns the policy through his employer.
    Example #2: Jane Doe is seen at the doctor.  She works for XYZ company and has an insurance policy for herself and her husband John.  The EOB would list Jane as the Patient AND the Guarantor because she owns the policy through her employer.
  • Facility/Physician Information – This could include information such as the name of the doctor who treated the patient or the facility where the patient was seen, their address, phone number, NPI (National Provider Identifier) and Tax ID.
  • Service Information – This section will include the date the patient was seen, the procedures that were done, what was charged and then several other monetary values that can be very confusing.¬† (That is exactly what this publication is going to go over. ‚ėļ)
  • Remark Code Details – These are codes that explain WHY the charges were processed the way they were.

If you receive this from your insurance company – it is NOT A BILL!!¬† Even if it states that you are responsible for a part of the balance.¬† A bill will come directly from the physician or facility – because that is who you owe if indeed there is a patient responsibility balance.¬† I’ll go over that more toward the end of this article.

When you receive an EOB, you will want to inspect it.¬† Like I mentioned in my “I am Angry” article, doctors are amazing and dedicate themselves to years of education to learn how to keep us healthy and to save lives, but not necessarily how to bill for it.¬† Some of them do get certified and learn the specifics, but many do not.¬† They hire coders and billers to take care of medical claims and billing and often times, the staff is just not trained properly.¬† Not to mention – we are all humans and are certainly make mistakes.

 

So first, you’ll want to look over the document and make sure things like dates, names, procedures, etc. are all accurate.¬† Now let’s get down to the numbers…

The numbers can really be confusing.¬† What the heck does “allowed amount” even mean and what are these crazy “adjustments” for?!

There is a lot of information in the Services section, but I am basically just going to explain the monetary values.  I will write an article on each one of these topics that is more in-depth and will try to remember to come back here each time an add a link to each section, but here is the basic breakdown:

Billed amount –¬†¬†This is the amount that the doctor/facility billed the insurance company.¬† Now I know that some of you may be thinking these prices are¬†ridiculous, but trust me – there is a reasonable explanation.¬† You honestly have no control over the amount that is charged here.¬† I will say that most doctors and facilities offer a significant discount for patients that have no insurance – but to be clear – that isn’t always the case.

Allowed amount –¬†This is the amount that the insurance company is willing to pay for the service provided to this doctor/facility.¬† Every insurance company has a different amount they are willing to pay for each service – it is not the same amount across the board.¬† You have no control over this amount either.¬† This is an agreed upon amount between the doctor or facility and the insurance company.¬† The list of pricing is called a Fee Schedule.

Deductible amount –¬†This is the amount you are being charged for the agreed upon amount of deductible you chose when selecting your insurance plan.¬† If you feel like this amount is incorrect, you need to call your insurance company – not the doctor/facility.¬† If the insurance company determines that they processed the claim incorrectly, they will correct it and send the updated information to the doctor/facility.

Coinsurance amount РJust like your deductible, the coinsurance is an agreed upon amount between you and your insurance company.  The doctor/facility has no control over this.  So if you feel this amount is listed in error Рagain, call your insurance company, not the doctor/facility.

CoPay amount –¬†This is also an agreed upon amount between you and your insurance company.¬† However, the doctor/facility should have verified your insurance and any copay amount that should be charged prior to your appointment.¬† This amount should have been collected at the time of service.¬† If the doctor’s office told you “not to worry about it”, this does not mean you don’t have to pay it.¬† It just means, for whatever reason, they decided to not make you pay it up front and they were going to bill you for it.

Note: To be clear, Deductible, Coinsurance and CoPay amounts are the responsibility of the Patient/Guarantor.  The doctor/facility does not have anything to do with deciding these amounts.  If you feel like the amounts on the EOB are incorrect you need to contact the insurance company.  If you were charged something OTHER than what is listed on the EOB, you should contact the doctor/facility at that point.  If they do correct the error and issue any necessary refunds, then you need to contact your insurance company and let them know.  They will contact the doctor/facility directly.  You can even ask them if they can do a three-way conference type call so that you can hear the response.  Not all insurance companies will do this, but some will.

Adjustment or Other Adjustments –¬†This one can get confusing, but it is really very simple.¬† Ok, so here is an example:
РA patient goes to the see the doctor for a sore throat, fever, and cough.
– The doctor examines the patient and determines the patient has an upper respiratory infection.
– The doctor codes the office visit with CPT 99214 – Don’t concern yourself with the codes at this point.¬† This example is really just about the adjustment amount.
– The doctor has determined the billed amount in his/her office for this service is $200 (this may or may not be accurate to what your doctor charges for this service – I’m just using it as an example for easy math purposes.)
– The doctor’s billing department submits the claim to the patient’s insurance company.
РThe contract between the insurance company and the doctor states that the insurance will allow $80 for CPT 99214.  This means every time this doctor submits a claim with CPT 99214 listed on it, to this specific insurance company, he/she will get paid $80.  (Not necessarily by the insurance company Рkeep reading!)
– If the doctor billed $200 and only got paid $80 – there is still $120 remaining.¬† This is the “adjustment”.¬† It is actually called a contractual adjustment.¬† This means that any difference in between what the doctor billed and what the insurance company allowed must be adjusted off.¬† The doctor cannot bill this amount to the patient.

Provider Paid – This is the amount the insurance company actually paid the doctor/facility.¬†¬†The above seems pretty simple – right?¬† $200 (billed) – $80 (allowed) = $120 (adjusted off).¬† Here’s the thing: just because the insurance company “allowed” $80 for CPT 99214 – does NOT mean that is what they are going to pay the doctor!!

If your EOB says:
Billed $200
Allowed $80
Adjusted $120
Paid $80
Then that means the insurance company paid the doctor EVERYTHING that is owed to him/her for that visit.  To be clear Рif the allowed amount and the paid amount match Рyou owe nothing.  Period.

However, if the allowed amount and paid amounts are different – that means that the patient is responsible for the difference – which will either be deductible, coinsurance or copay.

As an easy example, say you go to the doctor and the person at the check-out counter tells you that you owe $20 for a copay, then the EOB would read more like this:

Billed $200
Allowed $80
Adjusted $120
Paid $60
See the allowed is $80 and the paid is $60.¬† There is a $20 difference – that is the copay that you are responsible for.¬† If you paid it upfront on the day you were at the doctor, then you owe nothing.¬† If you didn’t then you will still be responsible for that difference.

In that case, the EOB would actually read like this:
Billed $200
Allowed $80
Deductible $0
Coinsurance $0
CoPay $20
Adjusted $120
Paid $60.

In addition, if you haven’t fulfilled your deductible yet and you are responsible for a copay, it could look like this:

Billed $200
Allowed $80
Deductible $60
Coinsurance $0
CoPay $20
Adjusted $120
Paid $0

Notice in that example, the insurance company allowed $80 – based on the contract with the doctor, but did not actually pay the doctor anything.

The allowed amount is what the insurance company and doctor agree the doctor will get paid for the procedure – but the payment could come from the insurance company, the patient, or a combination of the two.

This brings us all the way back around to the bill.¬† Remember an EOB is not a bill – it just explains how the insurance processed your claim so you will know if you need to expect a bill from the doctor/facility.¬† That is why it is SO important to review your EOB’s.¬† If your insurance company doesn’t mail them to you – they may only offer them online.¬† Make sure you look for an EOB for EVERY visit you make to a doctor/facility.

When you get an actual bill, it will be from the doctor or facility.  For every bill you get, you should have a matching EOB.  If you go see the doctor for a sore throat at his/her office, you should be able to obtain an EOB after the doctor files the claim and the insurance processes it.  If you receive a bill from a doctor and have not received your EOB, you need to contact your insurance company or log in to their member portal to view your EOB or request that one is sent to you.  Your doctor bill and EOB should match exactly in regards to amounts allowed, paid, due, etc.

The title of this post is:

How to Read Your Medical Bills – Is it Even a Bill?

You should be able to determine from an EOB what you should owe a doctor/facility and why.  If there is any difference Рsomething is wrong Рcall your insurance company asap!

In the case of a self-pay patient Рmeaning you have no insurance and only pay cash Рit is a little different.  You should ask every doctor/facility for all of the following things:

  • A list of each CPT or Procedure code and description that you are being billed for.¬† The specific CPT codes won’t matter to you, but the descriptions will.¬† This holds the doctor accountable for what they are charging and lets you know exactly what the doctor is stating he/she did for you.
  • What is the billed amount of EACH code?
  • What is their self-pay policy?¬† (Do they offer a self-pay discount and if so what are the terms.¬† This is very important because some offices only offer a self-pay discount if you pay in full at the time of service.¬† Some offices only offer a self-pay discount if it is asked for!¬† These are things you really should ask when making the appointment.)

This post may be a little lengthy, but hopefully it was helpful.  Please take a moment to scroll up top and add your email to the subscribe box so that you will be notified every time I post.

Full disclosure: Medical Billing is something that I am very passionate about.¬† I am a patient somewhere and so are all of my family members and it is very important to me that our claims are handled as thoroughly as I handle other people’s.¬† I am a work at home mom and not all of my posts are medical billing related.¬† Not only am I opening my own Coding & Billing Educational Consultant business in 2018, I have been an Independent Consultant for a children’s book company since 2011 and I own a photography company with my daughter.¬† Also – I am a wife-ish, mother, self-employed nerd and I post about all kinds of things.¬† I would love to share them with you.

Please take a moment to comment or ask questions below.  You can also find me all over social media:

Twitter: WAHMCat & Medical Billing
Instagram: WAHMCat
Youtube: WAHMCat (I don’t have a video to go with this post, but I’m working on one – Still go subscribe! ‚ėļ)
Usborne: Usborne website, Facebook Page
Photography: Shutterbug & Co., Facebook Page

Thanks for reading, commenting, sharing, following and subscribing.  You guys are the best.

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Catsiggy

Cat Clayton, CPC, CPB, CPMA
PO Box 121861
Fort Worth, TX 76121

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I am angry!!

Let me give a little recap… (this is¬†about the medical billing issue I’ve been seeing – please continue to read!)

I am a mom and for years I enjoyed casual blogging for fun.¬† I recently decided that I wanted to get into it again, but more seriously this time.¬† So… I hopped on my laptop and started a new “Welcome 2018” post.¬† It went well, I enjoyed it and hit Publish.

Then I thought to myself, “You know Cat, you’ve been away for quite some time.¬† You should reach out to each one of your followers, say hi and give a few of their posts a read.”¬† So I started to do just that.¬† But, with each click of the mouse and swipe of the screen, I kept finding accounts that haven’t been posted on in months – in some cases more than a year. ūüė¶

So, I decided to look for some new friends to follow.¬† I went to the main WordPress page and thought about what to search for.¬† Aside from occasional¬†art and hanging with my kiddos, my 3 favorite things to work on are my 3 businesses.¬† Two of them are hobbies, first, selling children’s books for Usborne Books & More and second is Photography.¬† The third is my profession: Medical Billing.¬† For whatever reason, I chose the latter.

I typed “medical billing” in the search box expecting to find another soul that is as intrigued by medical billing as I am.¬† (I know I am a giant nerd, but I am totally cool with it.)¬† The very first thing that popped up – was quite the opposite. It was an article titled, Billing and Bullshit (I will be happy to link back to the original article once given permission) complaining about a recent medical bill.¬† Or a set of them actually.¬† One where the patient was charged $86 for a procedure and then $43 for the exact same thing.¬† Also, $22 for a different procedure and then again $12 for the same one.¬† What?!

Now, without actually reviewing these bills and the procedure codes associated with them, I can’t say that there is an error.¬† What I can say is that all of that is confusing as hell, especially to someone who doesn’t do medical billing.

Then I came across another article titled Dollars and Senseless.¬† (Again, I’ll be happy to link back if given permission.)¬† This one was also frustrated with their bill.¬† One specific irritation was the “adjustment” amount of nearly $30,000.¬† I actually do understand that one without having to see any coding.¬† And when this person called to fight their bill, some charges were removed, but others were not.¬† When medical records were requested for review, it was going to cost $4 per page for over 40 pages.¬† So, since the original costs were less expensive than $160, they just paid them to avoid the higher cost of the research.

Not only is this an injustice and unfair to the patient, but also, if those charges were indeed incorrect – the insurance company now has incorrect information as part of that patient’s medical record!¬† And if the procedures were listed incorrectly – what about the diagnosis codes?!¬† What about the medications (which in this case was specifically what it was).¬† That could affect the patient’s overall healthcare! #Unacceptable!

One follower posted a comment stating that a doctor once told them that medical billing is more difficult to understand than medicine.¬† That is probably true in some ways.¬† I left messages for both authors and for a few commenters on both articles.¬† I told all of them what I often explain to other people.¬† Doctors are amazing!!¬† They go to school for years to learn how to save our lives!!¬† They are not taught specifically how to bill for it.¬† ¬†Sure, they learn a little along the way on coding and billing, but it just isn’t the same.

Coding and billing guidelines change quarterly – that is every 3 months.¬† Doctors are busy saving lives and learning the new technologies and sciences behind how to do it better every day.¬† There are some that do get certified in coding so that they understand this side of things better.¬† Most do not.¬† That is why they hire coders and billers.¬† There are a lot of crooked people in the world – some of them are doctors.¬† But honestly, that isn’t the biggest problem.¬† The biggest problem is the staff that is not trained properly to know the best practices for coding and billing!

I have been certified through the AAPC (American Academy of Professional Coders) as a CPC – Certified Professional Coder, CPB – Certified Professional Biller, and a CPMA – Certified Professional Mecial Auditor.¬† I am sitting for my CEMC – Certified Evaluation & Management Coder certification in 2018 and eventually my CPC-I – Certified Professional Coder – Instructor certification.¬† THAT is my passion!!¬† I want to educate!!¬† I want to help audit physician’s offices and educate them and their staff on the proper coding and billing guidelines.¬† More importantly, I want to help educate… YOU!!¬† Anyone reading this that is not in the billing industry!!¬† I want to help explain medical billing and the “mysteries” behind it.

So, in 2018, with my fun little hobbies and hopeful vacations – I really truly want to open my own medical billing education business.¬† I’m just getting started, and it may take a minute to find all the moving parts and get them all put together, but it will happen – and I can’t wait.

I know I can’t save the world and fight every crooked doctor out there and I can’t train each person that is currently billing incorrectly.¬† But, I can help educate other people and together we can make a pretty good dent in it.¬† And I can help educate people in general – so that they can be their own patient advocate.¬† No, it’s not saving the world – but it’s a start.

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Catsiggy