how to read your insurance explanation of benefits

Many are confused by the bill they get from a health care facility or provider, and understandably so. Remember to ask specific questions to the hospital, radiology, surgery center, or laboratory for better understanding and clarification of why you got charged what. Often, mistakes are made, and not in your favor unless you advocate for yourself. Hospitals often itemize things that should be bundled into one all inclusive service. Also, remember that if you go to a health facility you can get separate bills from a lab, a hospital, and from each of the doctors involved in your care, even if you have never met many of these people.Let\’s say the radiologist that reads your xray or mammogram or MRI. Or the pathologist that reads your biopsy, or the hospital group that rounds on you. In our office your bill may include a code for a certain level of service coded based on national formulas which take into account the number of diagnoses you have to manage and the number of medications you take. If you have 3 different diagnoses, let\’s say high blood pressure, high cholesterol, and elevated blood sugar, this represents more complexity, and the office is expected to code and bill higher than a simple runny nose or urinary infection. Even if the time spent is not more than a regular office visit, if you have multiple acute or chronic conditions, or if you take 3 or more medications, the code is for a level 4 visit. Interestingly, the insurers and medicare do not want you to bill in most cases, we are told, by time spent with the patient. So your complexity of service depends not on time spent with the health care provider usually, but on the potential diagnostic interactions, potential testing that can be ordered, or the potential severity of diagnostic options or end points. All very confusing, especially if the insurance bill says that a 99214 code is supposed to take 25 minutes of face to face time with the provider. 99214 is by far the most common billed code in an internal medicine office because of the complexity of medications, diagnoses, and potential treatment options, compared with a specialist who is only looking at one organ system and one medication, or two , that they are responsible for. This is all very complicated I know, and so no wonder many are calling for simplified billing and coding. Ask the billing people what the deal is and you will feel better informed about your bill.

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