We last left our hero (me) wondering,  “What in the world should I pay?”

Being unable to find out the information I wanted online, I called the BCBS MA member services line.  I provided my member ID and DOB through the IVR and waited patiently for someone to answer.  A very nice young lady picked up the line in what seemed like less than a minute.

I began dumping question after question on her and she patiently waited for my verbal vomit to subside.  She then told me that this was not a problem and that she would be happy to answer all my questions.  We started with what I had received.  She confirmed that the EOB that I had received from Emergency Physicians of St Petersburg on 6/20 was in fact a separate claim from the claim that the hospital had submitted.  She also confirmed that the EOB I received on 6/27 from Inpatient Consultants of Florida was also separate from the hospital claim.

I asked her what I should be doing with all these EOBs and bills, pretending that I knew very little about the process and she explained that the providers will submit claims, receive a response from BCBS MA and then generate a bill for the patient responsibility portion of the claim.  Some providers will generate a bill in advance of submitting the claim and request payment immediately.  In this case they’re estimating what the plan will pay.

This is where I told her that Bayfront Medical asked me to pay the full $2,900 deductible to which she said that I should not pay them anything until BCBSMA settles the claim because they may pay the whole thing and I would end up owing nothing.  She told me for example that I had already paid approximately $500 of my deductible so at this point in time, the most I would owe Bayfront would be $2,400.  To which I asked, “Well, what would happen is I had paid the full $2,900?  Should I expect a refund?”

She said that is how it normally would work but that I should pay close attention to the EOBs I get and match them to bills before paying anything.  I thanked her very much for her help – for she was truly pleasant and helpful.  I closed with one parting question…

“So you say I shouldn’t pay anything until I get my EOB and my bill but Bayfront told me they couldn’t generate a bill, only that I owed $2,900.  What do you think I should do there?”

She was gracious but non-committal and re-iterated that I should not pay anything without a bill to pay against, sage advice.

I guess the larger question at hand is this – how would someone who is unfamiliar with the entire claims processing and reimbursement model know this intuitively.  I looked around on the member portal and there is certainly a lot of educational material, but I didn’t see anything that stuck out that said:

Got Medical Bills and EOBs?  Here’s what to do next.

Regardless, she then confirmed that she did see a claim from Bayfront Medical for $11,264.14 that they just received.  She said I should allow for 30 to 45 days for them to process the claim and I should not pay any more money to Bayfront until that processing is complete.

So what have we learned so far?

1. There are numerous parties potentially to a care event that involves an emergency room and/or hospital stay.
2. Each party will file claims and bill individually.
3. EOBs and invoices show up at differing times.
4. Everything SHOULD match so if it doesn’t call your health plan right away.
5. Don’t pay money to a provider without a bill – you have rights, exercise them.

Next up on in our series I’ll dive all the way into the claim submitted by each providers to BCBS MA.  I’ll share:

• What procedures were claimed and for how much.
• Benchmark those against CMS data.
• Benchmark those against public price data.
• Speculate on what everyone’s gross margin might be – just for fun.