Re: Negotiating the back and forth between insurance and doctor billing
I deal with claim issues a lot in my business and try to help work through difficult claim issues for my clients. One of the things I have discovered is that (particularly with surgeries), if the surgeon tries to bill extra, for example, for an assistant surgeon, the carrier may deny the assistant surgeon cost as an "incidental" claim. In other words, the carrier thinks that the cost of the assistant surgeon should have been billed right along with the procedural code for the surgery itself, and the insurance carrier feels that that cost should have been part of whatever their negotiated rate with the provider was for the entire surgical procedure. In cases like this, it is sometimes necessary to file a formal appeal asking the carrier to review a letter of medical necessity from the doctor in order to get the claim paid. It's just a procedural step that can really be a pain in the neck, but oftentimes it is well worth filing the appeal. Instructions on how to file an appeal are always included at the bottom or somewhere in the text of the EOB (explanation of benefits), but a lot of people panic when a claim is denied and try to skip the formal appeals process by trying to work directly with customer service, which can actually prolong the process and make things worse.
You can kind of compare the above situation to getting your car fixed...just like you expect that the cost of the repair is the quoted cost and that you aren't going to get charged extra for parts that the mechanic forgot to order after the fact, the insurance carrier expects to pay only the negotiated rate, and they are typically unwilling to pay extra for things like assistant surgeons, when that type of cost isn't typically included in the negotiated rate for that particular service. So, in a case like that, an appeal with a letter of medical necessity is usually necessary.
Let me give you an example of how a provider once tried to abuse charging insurance carriers for the cost of an "assistant surgeon". What happened was, the surgeon was using the surgery room as a place to train interns, and then they were turning around and charging the insurance companies for the extra cost of having an "assistant surgeon" in the room. It didn't take long for the insurance carriers to wise up to what was going on, and now, that is why we sometimes see insurance carriers fighting over paying for those extra costs now. Usually, to fix the problem just requires an appeal along with a letter of medical necessity now. It's an extra step for the patient, but if the abuse had never happened in the first place, we probably wouldn't be in this boat of having to fight back and forth on situations like this.
Now sometimes, the carriers deny claims as "duplicates" if the insurance carrier finds a claim in the system for the same exact procedural code, date of service, and billed amount as one that has already been paid. This can sometimes happen when there is bad timing and a provider has resubmitted a claim after a claim has already been paid. If you ever get a claim that is denied as a duplicate, you can call the insurance carrier and find out when the original claim was paid and you can also ask them to provide you with the amount that either was applied to deductible, coinsurance or copays (if applicable).