Key Billing Information often not provided to patients

 

If you are facing a medical fee that is unjust, a hardship, or you wish to contest in any way, it is suggested that you secure the same information used to bill your insurance. If you do not have insurance, this information is perhaps even more important to any resolution.

1 Diagnosis Code

This code represents the meedical assessment and reason for services. This can be pivotal in some claims payment issues. It may also be incorrect and pose potential issues for some.

2 Place of Service Code

This indicates where services were rendered. Some services are not payable unless rendered in a specific setting

3 Procedure Code and Modifiers

A Procedure Code is critical to communicate the specific service that was provided and the amount to be reimbursed.

A modifier provides additional information that may in some way “modify” the claim processing.

Example – If a Radiologist read an X-Ray, MRI, Ultrasound, or CT Scan and wrote a report but did not actually take the images (very common in Emergency Departments) then a modifier would apply. In the Emergenct Department, where the hospital owns the the equipment, provides the supplies, as well as the staff such as a Technician to perform the radiology study a Modifier -TC (Technical Component) would be added to the hospital bill for the service and Modifier -26 Professional Component would be added to the Radiologists billed claim for the reading and interpretation of the images as wellas writing a report. This allows for the total amount allowed for the procedure to be divided between 2 parties separately providing a portion of the service.

4 Diagnosis Pointer

This supports that a service provided is justifiable. If an X-Ray of the ankle indicates that the person had a diagnosis of headache, this would be medically quesionable. In addition, some fees (especially “Visit” fees)  cover other services unless they are performed for distinctly unrelated diagnoses.

5 Charges

This is where the provider indicates the amount they are charging for the item or service provided.

6 Accept Assignment

Accepting assignment at the simplest definition allows the insurance carrier to make payment directly to the medical provider. (The custom of a medical provider billing insurance on behalf of the patient and not requiring payment at the time of service is founded on this “assignment”) Depending on the state and the typr of coverage, assignment may or may not have other significance.

Requesting Your Records

 

If you are contesing your bill or facing a hardship and need to negotiate your amount due, it is highly recommended that you collect as much information as possible. If cost to request lengthy records is a concern you may request the billing records only. However, since many states allow a clerical fee, should more complete records be necessary at a later time, this may result in a second clerical fee thus making the end cost higher than requesting records in a single request.

Template For Requesting Billing and Medical Records

The template below may be used to request medical and billing records.

Be sure to review and amend template appropriately and accurately. Leaving instructional notations may reduce the letters credibility should further action be required.

Information on allowed fees by state for medical records may be found at:

State-by-State Guide of Medical Record Copying Fees

 

[Your name]
[Your address]
[Date]

[Name of care provider or facility]
[Address]

Re: [Your medical identification number or other identifier used such as Patient Account number]

Dear ______,

I am hereby requesting complete and accurate copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations and to include billing records related to the enclosed billing statement. Please provide all DRG’s (if applicable), procedure codes, modifiers, place of service, and indication as to assignment of benefits as utilized in submitting claims to other parties for payment.

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment.

[Identify records requested (e.g., medical-history form you filled out; physician and nurses’ notes; test results; consultations with specialists; referrals).]

I understand that you may charge a “reasonable” fee for copying the records but will not charge for time spent locating the records. Please mail the requested records to me at the above address.

I look forward to receiving the above records within thirty days, as specified under HIPAA. If my request cannot be honored within thirty days, please inform me of this by letter and provide the date by which I might expect to receive my records.

I request that any adverse billing activity be suspended while you are fulfilling this request as well as any “account aging” not be accrued while I am without this information.

Sincerely,

[Your signature]
[Your name printed]