An open letter to KSB patients explaining healthcare billing
In most industries, paying for a service or item is straightforward. You see the price; you make the payment and receive the item or service. The entire transaction takes a matter of seconds. Healthcare reimbursement is far more complicated.
The biggest difference is that in healthcare physicians and hospitals are paid after services are rendered; and is a month’s long process with multiple steps.
The purpose of this letter is to explain these steps.
- Upon providing care, KSB staff and physicians document important details regarding the service(s) you received in the electronic medical record.
- Then, Certified Medical Coders translate the documentation into codes that payers (insurance companies) use to understand what services were performed, and why.
- These codes are placed on a claim that is sent to the insurance company, where they are reviewed before payment is made to KSB hospital and/or physicians. Each service or procedure has an associated payment rate based on the work required to perform the job.
- When payers review the claim, they may reject or deny all or some of the claim. Reasons for payers to reject the claim are:
- Services are not covered by the health plan
- There is a lack of medical necessity for services
- Some services shouldn’t be billed together during a single visit
- Coordination of Benefits- if this is not completed by the patient, the payer will deny the claim
- There are hundreds of reasons for payers to reject claims
- Payer review of the claim can take months to a year or more to complete.
- If a claim is rejected or denied, KSB makes every effort to appeal- until all efforts are exhausted. This appeal process may take months to a year or more.
After all these steps are completed, and all insurances that you have are billed; you may owe a balance. The balance, or “patient responsibility” is determined by your health plan. It is deductible, copay and non-covered services.
KSB works diligently every day to ensure that the claims sent to your insurance plan, and ultimately the statement you receive is correct and received timely.
There may be times where you receive a patient statement in a timeframe that is longer than you would like, and we understand your frustration.
KSB underwent a system conversion recently, and this can impact the timeline for claims to process through the system.
Please know that we are taking every step to ensure that the claims we send to your insurance company are correct, and we challenge denials by the insurance company so KSB can continue to provide safe, high-quality care for you and your family.
If you have any questions or need more information, please contact (815) 285-5982