posted on Mar, 6 2010 @ 01:16 PM
I have worked in the health insurance field for 7 years as a billing manager and patient advocate. I have worked for chiropractors, pharmacies, and
hospitals...oh, the sickening stories I could tell you. Anyways, with the experience I have, I will tell you this: The hospital is wrong to charge
her prior to billing the insurance company. See, the billing process is simple but fickle. First, your sister will be admitted, deliver her child,
and spend a few days in the hospital for recovery. When each procedure is performed, the doctor makes note of it. Eventually it works it's way down
to the medical billers and coders, who both provide appropriate diagnosis codes/procedure codes, and then bill the insurance. After anywhere from 15
to 30 days on average, the EOB or Explanation of Benefits is mailed to the hospital, along with a check or a bill. Every insurance company is
different, but they all operate the same, be it private third party insurance, Medicare, Medicaid, etc.
Until the hospital receives the EOB from the insurance, the only information they have on your benefits is via the phone call they placed to verify
your insurance when your sister became a patient there. CSR's for insurance companies generally fit into the 18-26 female demographic, as well as
generally having incomplete education. Whatever they tell the hospital is all the hospital has to work with until they receive the EOB for services
Insurance companies love to change benefits on a monthly basis with no warning, so what is true this month is not necessarily true next month; as a
result, even when an EOB is received, the hospital cannot guess as to what the next payment or bill might be. Everything is pure estimation.
They might be charging her $600.00 because they ASSUME that her portion of the bill will be about that much, but they cannot KNOW this. If she pays
the $600.00 and the insurance company responds that she only owes $300.00, then the hospital has to hand out a refund, which is a long and arduous
process...because honestly, who wants to give back money? Most patients won't even fight for it, and in the end the hospital writes off the excess
and it disappears into the coffers of the management.
If you have any more questions, or if I seemed vague on anything, just let me know.