When Your Doctor Doesn't Bill Insurance on Your Behalf
Going to a medical practice that doesn't bill insurance on your behalf can mean doing a little more of the insurance work yourself.
That doesn't necessarily mean your insurance won't cover your care. Depending on your plan, you may be able to submit your own claims for reimbursement.
1. Call Your Insurance First
Before your appointment, call the number on your insurance card and ask:
Do I have out-of-network benefits?
Will you reimburse me if I pay my provider directly?
Do I need a referral or prior authorization?
What is my deductible and coinsurance?
How do I submit my own claim?
What paperwork do you require?
Is there a deadline for submitting claims?
Write down the representative's name, the date, and any reference number.
2. Ask Your Doctor's Office for Documentation
If the office doesn't bill insurance on your behalf, ask what documentation they provide for self-submitting claims.
You may need an itemized receipt, superbill, procedure codes, diagnosis codes, provider information, and proof of payment.
Ask your insurance company what they require so you know what to request.
3. Submit Your Claim
Follow your insurance company's instructions for submitting a claim.
Keep copies of everything you send.
A simple folder on your computer or a paper folder can help keep track of:
Claims
Receipts
EOBs (explanation of benefits)
Prior authorizations
Denials
Appeals
Insurance correspondence
4. Read Your EOB
After your claim is processed, your insurance company will send an Explanation of Benefits (EOB).
Check:
What was submitted
What insurance allowed
What insurance paid
What was applied to your deductible
What was denied
Why something was denied
An EOB is not necessarily a bill. It explains how your insurance processed the claim.
5. Don't Ignore a Denial
If your claim is denied, find out why.
Sometimes the problem is something that can be corrected, such as missing information or a coding error. Other times, you may need to appeal the decision.
Check the denial for:
The reason for the denial
How to appeal
The appeal deadline
If you appeal, keep copies of everything and keep track of your deadlines.
The Bottom Line
When your doctor's office doesn't bill insurance on your behalf, you become the person connecting the doctor's office and your insurance company.
It can take some extra work, but you don't have to figure it all out at once.
Ask questions. Keep your paperwork. Track your claims. Watch your deadlines.
And remember: your insurance company can tell you what your plan covers and what you need to do to request reimbursement.
