Medical Billing - How It All Comes Together
As outsiders, we seem to think that the medical billing world is a nice neat little package. The truth is, the world of medical billing is anything but neat. Sometimes, many pieces have to be brought together before a bill can even be sent, depending on what you have done. Some procedures are simple. Then there are those that can turn into total nightmares. What follows is a true story to show you how complicated this can get.
A patient goes to the doctor for a routine checkup. During the checkout, it is discovered that the patient has some calcium buildup. The doctor explains to the patient all the things that this could possibly be including, most unlikely, TB. But just to make sure, the doctor gives the patient a TB test. Well, low and behold, the test comes back positive for TB. Now, it turns out that the patient works with a lot of immigrants who are probably in the country illegally and therefor there is a real possibility that the patient has TB, though it could be a false positive.
The next step is that the patient has to get a chest x-ray to determine if it is a false positive or if the patient really has TB. So, the patient is then sent from the doctor’s office to an imaging center to get a chest x-ray. After the patient gets the chest x-ray, which turns out to be negative, the patient then has to go and get a blood test to determine if there are any blood and/or liver problems that would prevent the patient from getting a pill for the next nine months to keep the patient from actually getting TB. The patient is then sent to a lab to get a blood test.
So, let’s review where we’ve been. We’ve been to the doctor for a checkup, covered by insurance, an imaging center for a chest x-ray, also covered by insurance and finally a lab for a blood test, which is also covered by insurance. Turns out that the x-ray is not covered by the patient’s primary insurance but is covered by the secondary insurance.
Okay, ready for the billing procedure for this nightmare? The doctor submits a bill to the primary carrier. The lab submits a bill to the primary carrier. The imaging center also sends a bill to the primary carrier who rejects the claim. The imaging center notifies the patient who then has to submit the bill himself to the secondary carrier. The secondary carrier then sends requests to the doctor and the lab to see what other things were billed for this condition before they finally pay on the secondary claim.
If this had been handled by a medical billing agency, they would have sent all the bills at once on behalf of each place and the paying of the claims would have been handled automatically by the various carriers, including the secondary insurance.
So, if you think medical billing agencies don’t perform a valuable service, this is one example where they save the patient and medical facilities a lot of grief.
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Michael Russell Your Independent guide to Medical Billing |
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