1) Do I really have Medicare?
Once you qualify for Medicare, you have the option to choose a Medicare Advantage Plan. Medicare Advantage Plans are policies that are administered by a third party commercial insurance carrier. They may offer additional benefits that traditional Medicare does not cover; however, it is important to note that these plans are completely separate from each other. Companies that offer Medicare Advantage plans receive the same funding from the government that Medicare does, but they target healthier, active lifestyle members and focus largely on preventative care. Some people may not know that they have a Medicare Advantage plan and present at the doctor's office with their traditional Medicare card. This can be a problem because a health care provider who participates with traditional Medicare may not necessarily participate with the Medicare Advantage plan. If you are unsure which plan you have, contact member services at Medicare to get the additional clarification you need, so you don't end up responsible for a non-covered medical treatment.

2) When is it important to open the mail from my insurance carrier?
While it is our job to navigate through insurance policies to get your claims paid, insurance carriers will often reach out to the patient for additional information before approving payment on any given treatment date. There are three different pieces of information that your carrier may request from you, based on your condition or type of treatment:

1. Coordination of Benefits. Every year or two, carriers will contact you to see if you have any other insurance, i.e. through a spouse or parent. This is to make sure that they are your primary carrier, and that your claims shouldn't be processed by another carrier first.
2. Accident details. There are certain diagnosis codes that suggest a patient may have been involved in an accident. In this case, the carrier will send out a questionnaire for accident details to determine whether or not a worker's compensation or no fault insurance carrier should be responsible for the claims instead.
3. Pre-existing questionnaire. These will probably be phased out due to new federal regulations; however, they are often sent to patients who have been members of a given carrier for less than a year when claims are first received. These questionnaires can easily be avoided by submitting proof of prior coverage to your insurance carrier when your new policy begins.

3) Is my Doctor really in my network?
If you or your employer has purchased an insurance policy offered through the Affordable Care Act's health insurance exchange, be sure to check to see if your doctor is participating. Each insurance carrier has several different plans or products that they offer to the public to purchase. They can have slightly different names, for example, Blue Cross Blue Shield PPO plan, Blue Cross Blue Shield Pathway Network, Blue Cross Blue Shield HMO, etc. Contracts between these carriers and healthcare providers can either include all Blue Cross Blue Shield plans or just certain products. Many doctors who have been participating with Blue Cross Blue Shield have been excluded from the specific plan offered through the New York State insurance exchange. Additionally, it is very difficult to determine which healthcare providers are participating, as many of them do not know, and customer support has been over extended during the implementation period.

4) Why did my doctor collect a $50 copay, when the EOB states I should only pay $46?
As co-pays, co-insurance, and deductible amounts are increasing, so are the uncomfortable conversations between healthcare providers and their patients. In an effort to make them less uncomfortable, keep the following information in mind when speaking with the patient about the subject. The contracted rate for a simple office visit or diagnostic procedure may be less than the designated co-payment. For example, a 15 minute office visit may reimburse the doctor $46 according to their contract with an insurance carrier. If, in this scenario, the patient's co-pay is $50, the insurance carrier will pay nothing to the doctor and the patient should only have to pay the $46. If the doctor chooses to waive this co-payment as a courtesy to the patient, the doctor will receive no payment for the services rendered. Also keep in mind that while most doctors are willing to work with patients on their portion of the costs, with a payment plan or reduced cost, they are contractually obligated to collect these payments from patients.

5) Why are there 5 different bills for my surgery?
Sorting out medical bills after a surgical procedure can be overwhelming and confusing. From the pre-operative screening to the final post-operative follow up appointment, there are several different healthcare providers that may bill for services rendered:

1. Physician charge for pre-operative screening (taking history and/or physical)
2. Lab charge for pre-operative screening (blood testing)
3. Professional surgeon charge for surgery (the doctor who actually performs the surgery)
4. Facility charge for surgery (the place surgery is performed, including equipment, nurses, etc.)
5. Anesthesiology charge for surgery (the doctor who administers and monitors general anesthesia)

To be proactive, you may want to check your insurance benefits for each of the different types of medical charges associated with a surgical procedure. For example, you may have a deductible or co-insurance for lab or facility charges, and not for the professional physician charges. Additionally, the facility may be participating with your insurance plan and the physician performing the surgery may not be. In this case, there may be additional patient responsibility. It's always a good idea to discuss any payment issues with your physician prior to having any surgical procedures.

6) Why do I have a deductible and a co-pay for the same visit?
Although your doctor may be participating with your insurance plan, there may be additional costs to you when certain diagnostic tests or x-rays are performed. In an effort to cut down on costs, many health insurance providers have implemented "cost-sharing" on office procedures. What does this mean? The basic examination of the visit, which includes taking a history, a physical examination, and setting a course for treatment, is all included in the office visit charge. The patient is typically only responsible for his or her co-pay for this portion of the visit. If the provider then performs an x-ray or office procedure, there is a separate charge to the insurance carrier. Some plans will cover 100% of these charges, while other plans will cover a percentage. For example, if I have a $30 co-pay and a 20% co-insurance for radiology or office procedures, and I receive an examination and x-ray at a doctor's office, I will be responsible for my $30 co-pay and 20% of the approved fee for the x-ray. If you are unsure or concerned about incurring additional charges during your examination, you should discuss it with your doctor or the doctor's billing office to avoid any surprises.

7) Why does the explanation of services on my EOB indicate a 45 minute visit, when I was only in the doctor's office for 20 minutes?
There are several different codes that doctors and other healthcare providers use to submit for insurance reimbursement. Among them are office visits codes, otherwise known as Evaluation and Management codes, which typically begin with the numbers 99XXX. Each code represents either the length of time spent with a patient or the level of complexity of the visit. The intervals of time generally range from 10, 15, 20, 30 or 40 minutes, while levels of visit complexity range from straight forward, low, moderate, or high. For example, the code 99215 can be chosen for the visit for either 40 minutes of treatment time or a visit of High complexity. So, even though you may not have been in the office for the full 40 minutes, if your case qualifies as highly complex, the use of the 99215 code is acceptable and valid. The different levels of complexity follow strict guidelines that are monitored by medical review and random audits.

8) I was treated by Dr. Smith; why does my insurance statement list Dr. Doe?
When a physician develops a private practice, he or she must create a business entity for tax purposes. In the case of solo doctors, the name of the practice often becomes the physician's name, followed by the type of business entity. PC stands for Professional Corporation and PLLC stands for Professional Limited Liability Company. So, the business name of Dr. John Doe's private practice would become John Doe, MD PC or John Doe, MD PLLC. In our hypothetical scenario, Dr. Smith is a physician employee of John Doe, MD PC, and any treatment rendered by him would be billed to a third party commercial insurance carrier under the business name of John Doe, MD PC. Thus John Doe, MD PC will show on the insurance explanation of benefits.

Matt Dallmann is President of the business consulting and physician education group, Creative Practice Solutions. He also contributes monthly blogs on physicianspractice.com, and provides outside opinion in featured editorials on MedpageToday.com. Matt has developed business educational activities available for CME credit to physicians and CEU credit to certified professional coders. These activities are available through CreativePracticeSolutions.com and their strategic partner, The DoctorsChannel.com.
Matt has spent the last 12 years in private healthcare management, consulting and medical billing. He is Vice President of the boutique medical billing firm, VGA Billing Services, Inc., based in New York City. Matt's investigative style of billing and collections has allowed him to resolve some of the toughest insurance issues that would otherwise require legal action.

Matt contributes monthly blogs to the national physician's resource, PhysiciansPractice.com, and has developed business educational activities available for CME credit to physicians and CEU credit to certified professional medical coders. He has also provided outside opinion on featured editorials on MedPageToday.com and contributes editorials in BC Advantage magazine, as well as the AAPC's Healthcare Business Monthly magazine. Matt has additional background in film, production and performance. His films have screened at film festivals throughout the country and his original music has been licensed for commercial use. This experience has given him an "out of the box" perspective in his approach to the business of medicine, and has allowed him to bring fresh, effective ideas to the table.