Still getting bills after insurance pays? You’re not alone — and it’s not always an error.
Read the blog to uncover what’s really going on and how to take control.
- Insurance Doesn’t Always Cover Everything
- The unmet portion of your Deductible
- Copayment
- Coinsurance
- Charges for Non-covered Services
- Out-of-network Costs
- Balance Billing
- Medical Coding or Billing Errors
- Prior-Authorization Requirement
- What Can You Do?
- Quick Patient Checklist for Unexpected Bills
- Conclusion
Insurance Doesn’t Always Cover Everything
Most health insurance plans are designed to share the cost of your medical bills and do not cover it 100%. Many people assume that insurance policy will cover all the medical expenses for the care they receive, but it can be frustrating to find unexpected medical bills even after the insurance has reimbursed the payment.
It is quite common in the healthcare billing process to get a bill after your insurance has paid and results from the complexities of insurance coverage and cost-sharing arrangements.
When you get medical treatment, your doctor files a medical claim on your behalf with your insurer. The insurer then reviews it based on your health plan, taking into account your deductible, copayment, coinsurance, and the contract rate for the medical services. If there’s missing medical documentation or errors, it may affect what is covered. Your insurance will pay a portion of the cost according to these factors and the agreed-upon rates with the provider for the service. The remaining balance is the bill sent to you, and it is your responsibility to pay it. This includes:
- The unmet portion of your deductible
- Copayment
- Coinsurance
- Charges for non-covered services
- Out-of-network costs
- Balance billing
- Medical Coding or Billing Errors
- Prior-Authorization requirement
The unmet portion of your Deductible
The health insurance deductible is your out-of-pocket expense for covered healthcare services, which must be met before your insurer begins payment. You’re required to pay the cost of covered services until you meet the deductible amount. The bill may reflect the portion of the service cost that applies to your remaining, unmet deductible.
Copayment
Copay is the fixed amount you pay for specific medical services such as a doctor’s visit. This may also apply even when your deductible is met.
Coinsurance
Some healthcare plans include coinsurance, meaning you have to pay a set percentage of a covered service cost after meeting your deductible. The bill could be for your coinsurance portion based on your cost-sharing plan. This still contributes to your total medical expenses.
Charges for Non-covered Services
These are the costs for medical services that your health insurance plan doesn’t cover. Therefore, you are responsible for paying the remaining balance which will not contribute to reaching your out-of-pocket maximum. These services might also not be eligible for healthcare financing programs.
Out-of-network Costs
If you wish to see a provider who is out-of-network, the insurance company may cover a portion of your medical expenses, or none, leaving you with a bill to pay. Out-of-network expenses are not applied to your out-of-pocket maximum. Out-of-network providers may also result in balance billing, increasing your total bill.
Balance Billing
This is more common when you visit out-of-network providers who charge you the difference between their fee and what your insurance covers. The billed could be the balance amount.
Medical Coding or Billing Errors
You may receive a medical bill as a result of a medical coding or billing error in healthcare. Occasionally the issue is not with your plan coverage but from the provider’s office due to an incorrect CPT code, documentation error, or duplication of services which can lead to inaccurate bills.
Prior-Authorization Requirement
Many health plans require prior authorization for certain services such as medical procedures, tests, and treatments. The procedure involves the providers submitting medical records for insurers to review. Medical claims may be denied without approval, making the patient responsible for the service cost.
What Can You Do?
Review the Explanation of Benefits (EOB): EOB is a document from your insurer that outlines what was billed, what they paid, what wasn’t covered, and why you may still owe a balance. It is very important for you to understand your Explanation of Benefits (EOB).
Compare it with the bill received from your provider and check what your financial responsibilities are.
Contact Your Insurance Company: Call your insurance company asking them to explain the charges, coverage, and any differences, if you don’t understand the explanation of Benefits (EOB).
Contact the Provider’s Billing Office: Call the billing staff, provide EOB information. Discuss your bill with them and clarify any charges.
Know About Appeal Options: if you find any errors in the bill that a service was wrongly billed or denied, you can file an appeal with your insurance company.
Quick Patient Checklist for Unexpected Bills
- Use this list to understand and manage your charges:
- Review your Explanation of Benefits (EOB)
- Match your EOB with the bill you received
- Check for medical billing errors or duplicates
- Contact your insurer for clarification
- Speak with the provider’s billing office
- Ask about your deductible, copayment, or out-of-pocket maximum
- Appeal if something seems incorrect
Conclusion
Receiving a bill after your insurance has paid its portion isn’t an uncommon aspect of navigating healthcare financing. It often reflects your portion of the expenses such as deductibles, copays, or coinsurance based on the cost-sharing design of your plan. Understanding the details provided in your Explanation of Benefits (EOB) and proactively reaching out to both your insurer and provider’s billing department when you have questions, empowers you to clarify your responsibilities, ensure accurate billing and resolve unexpected charges.
Need Help Reading Your Medical Bill or EOB?
Contact Integrate Point — we help clinics and patients simplify medical billing, verify prior authorizations, and spot EOB errors fast.
Never knew this, regards for letting me know.