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1 thought on “Translating Insurance Language into Mainstream English”

  1. Medicare has slightly different policies. After the patient assigns benefits to a provider, participating physicians and facilities receive their funds directly from Medicare; in other words the patient is not an intermediary in the transfer of released Medicare funds to the provider. The provider can not balance bill the patient for that part of his charges Medicare does not allow.

    Several years ago Medicare allowed for anesthesia less than its annual deductible; the amount was less than $150. Accordingly Medicare determined its allowable of the submitted approximately $700 anesthesia fee. It did not pay its allowed fee, but sent it onto my medicare supplemental insurance. This insurance wrote a check for the entire allowed fee and sent it directly to the anesthesia group, a participating provider.

    Yet I received a balance bill of approximately $535. I called the practice office and asked “are you a participating medicare provider?” When the secretary replied “yes”, I explained that the practice had a contract to discount the $535. Yes she agreed.

    The slope became slippery when I asked why I had received this bill. Oh she said “someone made a mistake.”

    I did not confront her with the following facts. 1. I knew this practice was a participating provider before I called. 2. Medicare guards the door into my supplemental insurance as carefully as the secret service guards the doors into the White House. Medicare knew my commercial insurance was secondary. 3. Someone changed my commercial insurance in the billing system from secondary to Medicare to primary commercial. Someone sent me a balance bill. Someone hoped I would write a check. Someone did not know I had managed a medical practice.

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