If you receive an unexpected bill months after the doctor’s appointment, it can be confusing and frustrating. Haven’t you paid this yet? Why did the price change?
Although it is rare, health insurance claims are sometimes amended. The reasons are various. Sometimes there is a conflict between your doctor and your health insurance company, or an update that changes what your insurance pays. Most of the time, it’s not anything you did or didn’t do.
Let’s talk about claims exchanges, how they work and why they happen.
What is a statement switch and how does it work
When you see a doctor or other health care provider, they send a medical claim to your insurer for payment. During this billing process, your insurance company will review the claim, determine what your insurance plan covers and pay your plan’s fees for covered services.
Generally, the claims process is not without any problems, but sometimes they need to be reviewed. This is where complaint handling can come in.
Your insurance company may request additional information to process the claim. If it determines that a change needs to be made, your claim will be processed. When your health insurance company reviews and amends the original claim so that the payment amount is correct, a claim amendment is filed. They will usually tell you about any changes to your claim if it affects your credit.
HealthPartners members may contact member staff for any questions regarding health care claims
These are common for claim settlement
There are various reasons why your statement may be changed. Here are some common situations that may cause the insurance company to review a claim.
The healthcare provider is changing
Your doctor’s or provider’s fees vary
A claim adjustment can happen when your provider changes how much they charge for a service. Rest assured, these price changes are not random, they are pre-planned. Most contracts between network providers and insurance companies are renewed at the beginning of each calendar year. During this process, the price may change. However, this time may be different. For example, HealthPartners sometimes renews provider contracts on July 1. New contracts, whenever they happen, can result in a claim adjustment if a member receives care before the new bill goes into effect in the billing system.
Your provider should fix or update their bill
Although many providers have good reviews at their clinics, sometimes they charge for the wrong service or procedure, such as a 45-minute doctor visit rather than a 30-minute visit. Depending on your insurance company, these issues may be identified quickly or may involve a bit of back and forth between your doctor and the insurance agent.
At HealthPartners, if a billing code error is found in a member’s submission, the provider generally updates the information by sending us the corrected code. This may result in the claim being amended based on the new code and may result in a price adjustment.
Providers usually have 12 months to submit changes to health plans if they find errors. This is why a claimant may receive an unexpected maintenance bill that occurred a year or more ago.
Member and Legal Change
The policyholder does not provide accurate information
When you or someone in your plan receives care for an injury, the details of how and where the injury occurred can affect how much your health insurance will pay. For example, if you were injured in a car accident and have car insurance, your auto insurance policy may be responsible for paying some of your medical bills before your health insurance kicks in. Because of this, health insurance companies may ask for additional information when processing a claim.
At HealthPartners, we sometimes ask members to return the Coordination of Benefits (COB) form to Employee Services (via mail or their online account) to get more information before we process their claim. The COB model tells our claims professionals if a member has other types of insurance (such as auto or home) that should pay first for certain types of claims. Without this information, the claim may be processed incorrectly, and claim changes may be made later.
The legal holder makes the request
Members sometimes choose to ask their insurance provider to make a claim, often when they believe that a denied claim must be paid. If the appeal is upheld, your statement may be amended to conform to the decision.
The termination of the policyholder’s plan has not been scheduled
Claims adjustment can happen when a claim is adjusted after the plan cover has lapsed. For example, if your insurance ends on February 28 and you go to the doctor on March 3, your doctor may unknowingly pay for the canceled insurance plan. If the plan limit has not been updated in the insurance system, the plan may pay the bill. In that case, your claim will be settled since you no longer have coverage under your health plan when you receive treatment.
The infant is not included in the parent’s coverage
Newborns begin receiving health care services immediately after birth. However, the legal parent has a window of time to include the newborn in their insurance. If the insurer receives claims for a newborn who is not yet enrolled in a health plan, the claims will be rejected. Once the child is added as a member, the insurer will reprocess the claims and change them to include the policyholder’s plan benefits.
Government regulators or employees change
The government changes the standard or rate of payment
Sometimes agencies like the Centers for Medicare and Medicaid (CMS) or the Department of Human Services (DHS) state update payment rates or payment standards. When this happens, it can teach insurers to make retrospective changes. This can lead to improved claims for members of government-sponsored programs, such as Medicare and Medicaid.
In addition, many payment rates for services that people do not receive in government plans are set at a certain percentage of the CMS cost. If CMS changes the cost of health services for Medicare beneficiaries, that could have a dramatic effect on those with non-Medicare plans and possible claims adjustments.
Your employer makes a benefit adjustment
When an employer makes a mid-year plan benefit change, the claim must be adjusted for health care services received at the time of the change. Fortunately, this phenomenon is not uncommon, since most employer-sponsored plans cannot be adjusted during the year.
Insurer data system error
Although it doesn’t happen very often, insurers can make mistakes. When that happens, your insurance company will fix the error as quickly as possible. By law, insurers can correct these errors up to 12 months after the initial claim.
At HealthPartners, an important part of our claims processing is automated, but there is room for human error. This is especially true when members receive care from non-contractors, since our systems are not set up to receive their claims automatically.
Our claims professionals are trained to work efficiently and effectively, and we do our best to avoid mistakes. We also conduct regular audits to quickly identify and fix errors.
Accusations of fraud
Sometimes the insurer will pay for a claim that is later determined to be fraudulent. An example is a claim for care that has not been received. In this case, the statement will be amended and rejected.
As a patient and member, you can help detect fraudulent charges by checking your statement of benefits (EOB) whenever they arrive. If you see something that doesn’t add up, like a referral for care from a provider you didn’t see or a service you didn’t get, call your plan’s member services.
Are claim revisions occurring across all coverages?
Claims adjustments can occur in many types of insurance, from private plans to government programs like Medicare and Medicaid.
Some claim changes may also affect a member’s Financial Adjustment Account (FSA) payment if the FSA has already been paid for the amended claim. Contact your FSA provider to understand what you need to do if that happens.
How a claim change may affect a health plan member
Claim revisions sometimes mean you owe more or more to your health care provider than originally thought. This usually results in an additional charge or a partial refund by your provider. It can also change where you are in your deductible or out-of-pocket health plan.
If you have questions about how a claim adjustment affects your plan balance or what you owe a provider, contact your plan support team.
How to know when your statement has been amended
There are two common ways for a member to learn about the exchange of claims. You may receive an unexpected charge or refund from your provider. Or you can get a new EOB from your health plan by mail or in your online account that lets you know that there has been a change. In both cases, you can call your support team for more information. They will be able to tell you in detail why your statement has been changed.
For HealthPartners members, if the claim adjustment does not change the member’s out-of-pocket amount, we do not send an EOB. For example, if you bill for a doctor’s visit and a claim change occurs that increases the amount HealthPartners charges the provider for that service, you will not be notified, since it does not change the amount you pay.
What to do if you’re confused about a claim change
If you get a bill from a doctor that surprises or confuses you, or you get an EOB that says there is an amendment, don’t panic. It’s time to call your insurance agent. At HealthPartners, that means reaching out to our Member Services team, so we can walk you through the details and address any concerns you may have.
Preventing or avoiding complaint corrections
Many claims changes occur for reasons beyond the member’s control. However, your participation in the declaration amendment process is important. Sometimes your insurance agent will ask for more information, and responding in a timely manner can go a long way.
Getting your care from an in-network provider is also a good way to protect yourself from unexpected costs. Insurance companies have contracts with network providers that protect members so they are charged for certain additional costs. Some insurance companies, such as HealthPartners, also require network providers to submit claims for members automatically, which reduces delays and the risk of errors.
Still have questions about claim adjustment? Our team members are here to help
At HealthPartners, we do our best to process claims quickly and accurately the first time, but sometimes claims need to be changed when new information becomes available. If you are a member of a HealthPartners plan and you have questions about claims, our member services team can help.
