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?
- There are numerous parties potentially to a care event that involves an emergency room and/or hospital stay.
- Each party will file claims and bill individually.
- EOBs and invoices show up at differing times.
- Everything SHOULD match so if it doesn’t call your health plan right away.
- 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.