- Created on 09/24/2008
An effort to help you understand your hospital bill and address questions frequently raised by our patients. It is our intent to provide you with an accurate and understandable bill for the hospital services.
Please call our business office at 737-3300 if we can assist you.
- Why are there so many bills?
- What will my insurance plan pay?
- What payment does the hospital receive?
- What do I do if I continue to receive computerized statements requesting that I pay my bill?
- How does my health plan calculate what I owe?
The hospital will bill the patient, the patient's insurance or health plan for non-physician services that are provided at the hospital. Services provided by the physician are billed separately by the physician's billing agent. Especially after a visit to the ER, Radiology, or after receiving Lab Work, you may receive a separate bill for some services. This bill cannot be paid at the hospital and in most cases must be mailed. [ Back to Top ]
If you have current coverage through an insurance or health plan, our Billing Department will gladly bill them and any secondary or supplemental plan you may have. Within a reasonable time period (Usually 30-45 days) you should receive an "Explanation of Benefits" from your insurance company, referred to as an EOB. This form should show you what your plan will pay and if you owe any deductible or co-payment. With some plans, including Medicare, you may have a supplemental plan that will pay your yearly deductible or co-payment. We strongly suggest that you become familiar with your insurance plan and know what covered benefits you have, including whether a pre-authorization is required . Your insurance agent also can be of great help regarding questions about your coverage. [ Back to Top ]
There are three basic reasons why you may get a bill:
Your insurance has been billed but has delayed payment
Your insurance has denied payment
The amount billed is what you are responsible for paying
Please call our Business Office to see if we have received any response from your insurance company or health plan. If your insurance has requested additional information from you so that they can process your claim, it is important that you respond promptly to their request. If your insurance company is delaying payment, your call to them directly can be effective since you are their subscriber and should be considered their valued customer. [ Back to Top ]
In many cases, the amount you owe is determined by the health plan policy rather than the hospital charges. An example of this is as follows: Hospital Charges $10,000 Plan's Discounted Rate -4,900 Amount paid by plan $4,410 Amount to be Paid by Patient (10% Deductible) $490 Total Paid to Hospital $4,900 Unpaid Hospital Charges or Revenue $5,100 Based on the health plan policy, the $490 that you owe is based on 10% of the contracted amount and not the hospital charges. [ Back to Top ]
One of the least understood facts is that about 85% of hospital bills are paid by an insurance company or Health Plan that disregards the actual hospital charges, as mentioned previously. Most of these payers have pre-arranged discounted prices which they have determined or, in some instances, have negotiated in a contract with the hospital As in the example, the average amount that these payers are actually paying the hospital is about 49 cents for every dollar billed. In the example, the hospital received $4,410 from the insurance company and $490 from the patient. The $5,100 is what the hospital must absorb and cannot bill either the patient or the secondary insurance. This is the case for 85% of our patients, including Medicare, Medi-Cal, and most preferred provider health plans and HMO's. [ Back to Top ]
The following is a glossary of terms often used at the hospital in the admitting and billing office:
INPATIENT: A patient that has a specific diagnosis and is admitted at least overnight.
OBSERVATION PATIENT: A patient that is admitted for observation and testing prior to determining the specific diagnosis and treatment. An observation patient may stay in the hospital overnight or several days before being discharged or admitted as an inpatient.
OUTPATIENT: A patient that is admitted to the Emergency Department or for Outpatient Surgery or other tests that do not require the patient to stay overnight. On occasion, an outpatient may stay overnight and be discharged the following morning without changing their patient status.
PRE-AUTHORIZATION: Most insurance companies or health plans require the patient or healthcare provider to seek approval before having expensive treatment or tests carried out.
This pre-approval or pre-authorization usually gives both the patient and the provider the assurance that the service will be paid for by the insurance company or health plan. If a patient is not given pre-authorization, the provider will still perform the test or treatment; however, the patient is the financially responsible for the medical bill.
DEDUCTIBLE: A yearly amount usually owed by the patient or family before other health benefits are paid by the insurance company or health plan. CO-PAYMENT: This is often a set fee which the insurance company or health plan requires the patient to pay each time a specific health care service is provided, such as a doctor's visit or an emergency room visit.
MANAGED CARE: this term applies to healthcare coverage in which the patient is required to be seen by a primary care physician who authorizes or "manages" all health care for the patient in order for the healthcare services to be paid for by the health plan. This could be either an HMO or a Preferred Provider Plan. [ Back to Top ]