How To Be Your Own Healthcare Consumer Advocate

Courtesy of: Montana Medical Bill Review

Overview: Medical Billing ProcessConsumer (patient) goes to doctor,

hospital, or other provider for prevention or treatment

Data collectionServices rendered and documented Billing document generated using

collected data and codes from patient’s medical record

Electronic claim form submitted by provider to insurance company (If no insurance, payment collected from patient.)

Provider receives payment from insurer in 30 days

Anatomy of a Medical Bill

Doctor’s Office Visit

Hospital

Physician Service – Inpatient

HCPCS CPT DRG

RBRVS CMS R&C

ICD-9CM ICD-10CM

Top 10 Things You Can Do to Help Find Billing Errors

Check Name Check DOB Check Account Number Check SSN Check New Patient vs. Established Patient Request a detail bill Check type and number of procedures (X-rays, lab

tests, EKG,etc.) Hospital bill – check inpatient vs. outpatient

status/number of days Check room rate – Private vs. SemiPrivate/ICU, etc. Check type and amount of medications

Working with Provider or Insurance Company to Correct Errors

Collect all your information (bills, account statements, EOB, cancelled checks, credit card statement, insurance policy number,etc.) and have it available to refer to, before you contact provider or insurance company customer service

Remain calm Smile when you talk on the phone Provide necessary information to verify your identity and account

number Briefly state your issue/concern/questions Ask for clarification of any charges or insurance payment denials Specifically identify billing errors Request a corrected bill If necessary, use the appeals process outlined in your insurance policy to

appeal a claim denial you believe is in error Follow up: review account statement from provider to confirm

corrections; review subsequent EOB from insurance company to confirm claim status/payment

Thank You !