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Medical bill receipt format for Planning

are you someone who's gotten a medical bill in the mail and you just can't make heads or tail of it and you just want someone to explain some of it like at least the basics so you have an understanding of what the heck they're talking about so today i'm going to explain the basics of the medical bill and then how you can find more information about why some of those procedures might not have been paid hey everyone i'm victoria i'm a medical coder auditor educator and content creator and on my channel i provide tips tricks and tutorials on medical coding but today i want to talk about medical bills and how you can get a basic understanding of your medical bill so the best way to do this is to actually walk through a couple of medical bills now i just want to say i have not obtained these from any current or past employers i have blurred out all of the private information but they were obtained with permission so let's just get into it and i can show you some of the things that you might want to look out for when you're just kind of reviewing your own medical bills so the first thing you're going to see here on that top line is how much this total was so this was the total charge that was sent to the insurance so this provider billed 576 dollars to the insurance and they adjusted off a good amount of it 289 dollars and 32 cents so that insurance payment is basically saying you know the provider billed you this much but we have a contract with you we're only going to pay you a portion of that so we have this contract and we've agreed that we're only going to pay a certain amount for types of services and you're going to adjust off the rest the patient responsibility total is 25 and then there's that balance due of 25. so the first thing you'll see here is this immunization so the patient was due for their flu shot it's flu season this is something that commonly if you go in for any kind of service from those dates where a flu are rampant they're going to ask you to get a flu shot with the flu shot there's actually two charges so there's one for them actually administering it so giving you the injection and the second is for the solution the actual drug that they're there of the flu vaccine so you may see that there's two charges there for one kind of service but they're really two different components of the same service the administering it and for the actual drug itself those codes that you see in the column there those are the cpt codes they're codes for different types of procedures so instead of having to send a huge note or summary or record to the insurance company that's all kind of textual things they just narrow it down to a code that they can go oh yeah we pay for 90460 we don't pay for 90460 or attach the fee to it it's a lot easier to do that with a code set versus a huge narrative of text so you can see here that 90460 is for the administration of that first component of that vaccine it was charged thirty one dollars they adjusted six dollars in insurance paid at 25. so the next one they charged thirty three dollars for the flu vaccine itself they adjusted off 1082 and then the insurance paid 22 18. next the patient also had a pure tone hearing test this was a pediatric patient they were due for some preventative measures and they had their hearing check that was 25 next under that you'll see the ocular instrument screening so ocular meaning your eyes so this patient had an eye exam but if you see that 10 was a ten dollar charge nothing was adjusted insurance didn't pay anything and it says the patient responsibility is ten dollars so i'm actually going to show you then how you can determine why that ten dollars wasn't paid so next we have an office visit and then underneath that you'll see a preventative visit so this is something that happens commonly with patients you go in for your scheduled preventative visit where they kind of check your head to toe and tell you you know it's time for your colonoscopy or you need to improve your diet or here's some things you can do to lead a healthy life and those are your preventative visits but sometimes during those there's a problem that gets addressed too that you might go into your provider and say you know i've had a cough for the past two days well they have to address that that's not part of your preventative visit so they actually charge you a separate fee for that or if maybe you go in and you have chronic conditions you know the fact that you have chronic conditions alone isn't going to mean there's an extra visit but if there's something wrong with them that they need to significantly address that they need to do things that's way above and beyond what's normally included in a preventative visit that maybe they have to call your specialist or order extra testing or do extra work they might bill for a separate visit for that so in this case that's what happened to this patient so they had this 99214 and that's for an officer outpatient visit so that's a visit that you might have at your primary care physician or internal physician even maybe your ob gyn if you're having a problem and they are on different levels so a level one visit might be a patient that is just coming in for a weight check or a blood pressure check and then they go up to a level five and a level five is a patient who maybe has a lot of chronic conditions they're having issues with them they're not being compliant and they have a higher level severity or the patient requires a lot of different care from that provider so that provider might have to talk to specialists you know spend a lot of time documenting they might have to examine other areas or order different studies or or review a whole lot of past historical notes so depending on what kind of problems you're having that you can fall anywhere between that level one through that level five so this patient was a level four meaning that they probably had something not super severe but something that required a lot of time consumption by that provider to maybe order extra studies or coordinate some care or talk to the patient and counsel them so in that case they have a copay so that's their office visit copay so that was charged 241 dollars insurance adjusted a good amount of that and they paid only 92 dollars and but the patient is responsible or whoever is responsible for the bill has to pay off 15 as that co-payment for that office visit the preventative visits are often covered at 100 percent because insurance is like you to go and get preventative care instead of problem-based care so that was paid off at the entirety you know the charge was 236 they they contracted to pay 105 for those services for this insurance so that's what they paid and everything else was adjusted so at the bottom of this you can see the responsibility is 25 and that's for the copay that's listed here and this 10 ocular instrumentation thing that wasn't covered so what you can do to find out more information about why something may not have been covered is you can go through your insurance and get the eob or explanation of benefits the explanation of benefits is the summary that your insurance gives you of all the information of why things may or may not have been covered through them depending on your insurance they might send you these in the mail or you might just be able to log on to your insurance website with your account information and they'll have them all listed for you all the information about why things may or may not have been covered so let's look at this one over here on this one for highmark this patient again i blocked out a lot of their information but you can see here here's all those different charges that they had and the insurance is giving you information about the co-pays and what was responsible and then where is this testing that they said that they did not cover oh here it is it says diagnostic eye procedure ten dollars there is non-covered and then it gives you this code here and it says see remarks and that c remark says see for mark u five zero zero six a so if we scroll all the way down it will tell us information here and here is our remark it says the patient's coverage does not provide for this service or diagnostic study as part of their preventative schedule therefore no payment can be made for this service so basically what it's saying is this patient you know they cover for preventative services but this isn't one of the ones that they cover for they didn't deem this patient maybe at their age interval or whatever that they they deemed it was something that they medically needed so they're just saying hey we're not going to cover for it the patient didn't really need it so sometimes this gets a little tricky with insurances because if you call them and ask them you know hey maybe why wasn't this covered sometimes they'll tell you it wasn't coded correctly by your provider and sometimes it's not just that it wasn't coded correctly it's that maybe that patient didn't meet the criteria to code it that way that gets paid there's a lot of things with screening versus diagnostic so let's say your insurance covers a screening mammography they want to screen you and make sure that you don't have breast cancer that screening is different from a diagnostic mammography so diagnostic mammography would be you know we found a lump in your breast and we have to diagnose what that is so that's not a screening service that's a diagnostic and for some things they will pay for screenings but maybe not diagnostics or they'll say you know we can't screen you for something that we know you that you have that maybe we don't pay for certain types of laboratory services because we know you have diabetes we're not going to screen you for diabetes because we know you already have it and sometimes there's those struggles between the insurance company and the provider and the provider saying yeah we coded it correctly based off of what you have and the insurance is saying no no they didn't code it correctly and if they coded it this way it would have gotten paid well if they'd have coded it that way that might have been something that have gotten paid but it would have been something that may not have been correct and the provider would not have been compliant so providers aren't really allowed to just change the codes just to get things paid so imagine you're going to a store and you find a product that you really like you take it up to the register that cashier can't go hey i just like you so you can just have that product for free i'll just mark it down to zero because that's not really their call to make and there have been providers who have wound up in a lot of legal problems because they just coded things to get paid because it's not really fair to the insurance companies and i know i'm sure some of you are probably very opinionated about insurance companies but it's not really fair to the insurance company that they just pick and choose and go hey these patients were we're not going to charge them anything but hey you aetna we're going to charge you 500 so as much as your physician may love you very much they could wind up in a lot of legal hot water and even lose their medical license if they start changing things just to get them paid when they're actually not compliant so the next thing i want to show you is that after this visit this patient had some studies that were ordered and had to have them completed so we got bills then for those as well so it looks like this patient had some ultrasounds done there were two different ultrasounds and they were done by the same tech on the same ultrasound one but they were done for two different areas so there's two different charges one of these was transvaginal and one of them was retroperitoneal so they were looking basically at two different areas and there's two different charges for these they're both 541 dollars there was an adjustment done and the patient's balance was actually a little over a thousand dollars because this went to the patient's deductible a deductible is the amount that a patient has to pay before insurance will start covering for services there are high deductible plans where you may have eight thousand dollars thirteen thousand dollars that you have to pay out of pocket before your insurance does and after that it doesn't mean that insurance is going to cover necessarily everything at 100 you might still have a co-insurance that you're still responsible for 10 20 40 of those bills after that deductible has been met and that can even change depending on if you're in network meaning that you're using the providers and and services that your insurance company really likes and they have special contracts with them or if you're out of network meaning you're not using the providers that your insurance company prefers that you use so in this case it all went to deductible and co-insurance so the patient is responsible for one thousand and eight dollars and twenty cents now the interesting thing is if you'll notice here it says that this was the technical service it's a service type there technical what does that mean so with things like studies ultrasounds x-rays etc there's two services that you might have there is the technical and then there's the professional so think about an x-ray the x-ray tech is going to go in use that x-ray machine and perform that x-ray that is the technical component that is the cost of them actually using that machine and then there's the professional component meaning someone has to look at that x-ray and interpret it and go oh yeah that was a fracture and write up a report saying exactly what they found so those are two different components that can be built sometimes the provider does both of them sometimes they're the one that owns that equipment so they bill you for that and the uh they do the the read they read that x-ray and do the interpretation and if they do both of those you might only get one bill but if those are two different providers or two different organizations providing those services you will get two bills so in this case you can see these are the same services but there's a lower charge and that's because this was the interpretation of those ultrasounds so the first bill was for the use of that ultrasound equipment and the tech and all of that but this is for actually looking at those ultrasounds and figuring out the diagnosis so in this case these are slightly smaller charges this one's only 77 this one's only 83 versus the 500 and some of the previous ones and then there is a it goes to that coinsurance again so there is a small amount of a percentage of it that's due and responsible by the patient or guarantor to have to pay for that so this patient had a thousand dollar deductible so they fulfilled that thousand dollars but they're still responsible for a small percentage of co-insurance after that so in this case they got a bill for the interpretation of that and it was just eight dollars and two cents so it's a lot to look out for and it can get very very confusing especially if you've got a lot of different bills and and it was for the same visit sometimes you know like i said you might go in for that one sort of ultrasound encounter but they're looking at two different things and then there's the use of the equipment and then also the interpretation of those results so there's a lot going on there so it can get very cumbersome to understand your medical bill but don't forget you have those eobs those explanation of benefits where they'll break down for you why things may or may not have been paid and even give you a number probably to call at your insurance company to get more information about your medical bills and what is and is not covered and there are specialists available that will help you with that information and if you're struggling paying your medical bills make sure you call those healthcare organizations and try to work with them about payment plans a lot of them are very good with setting up financial aid for patients that are unable to afford their care now i hope you found that overview helpful now i don't personally do denials resolution or review of personal medical bills but if you are someone who does or you know someone who does drop their information in the comments so that if anyone is looking for those sort of services they have someone to contact if you found this valuable i would really appreciate it if you give it a thumbs up and if you're interested in more billion coding content i would highly encourage you to subscribe and if you want alerts you can hit that notification bell so you will get pushed alerts when i post new episodes i hope i'll see you in the next episode and until then just keep on coding on [Music]