How to Use This Site

Medical billing is all about setting expectations

  •   What can I expect the patient to pay upfront?
  •   What am I expected to do, prior to the visit, to ensure accurate reimbursement?
  •   What am I expecting the health carrier to pay?
  •   Did the claim pay as expected?

The goal of this site is to provide the overall health insurance knowledge that is needed to set your expectations and recover what is due. 


I currently supervise the medical billing department of a large medical device company. Occasionally, we bring in temporary Medical Billers to assist with collections. Medical billing experience is required and health insurance knowledge is mandatory, however, I did agree to bring on a person who had just completed a medical billing course. Her task was to call health carriers to check the status on unpaid claims. She was asked to call the insurance carrier to check on a claim for $9000.00. Note: nothing was collected from the patient upfront. Here is how it went...

So without understanding the details of the plan, how do you know the plan paid correctly?

So let’s look at my expectations for this claim:

Patient has a PPO plan

80% in network - no deductible

50% out of network- $2000.00 deductible

$0 met at time of service.

Because we are an out of network provider, we had contacted the health plan, before service was rendered, to secure prior approval and a GAP exception. Both were granted.  The patient had a secondary plan that we expected to pick up the eligible balance; hence, no payment was required from the patient up front.


100% of the allowed amount between the two carriers – with a small portion as write off.

Clearly $2,800.00 paid on a $9,000.00 claim did not meet our expectations.

We called the health carrier back to dispute this payment.

End of Story:

We were told by the health carrier that the claim has been paid out-of-network in error. 

In spite of the clean claim, the pre-approval and the GAP exception - the claim was still paid incorrectly.  Because we challenged the payment, the claim was ultimately paid as expected, by both carriers, with a small portion going to write off.

Please note that NO time during our calls to the health carrier did they "catch" the processing error that they made. 

Had we not bothered to pursue this issue timely, we would have been stuck with a payment way less than expected.

The goal of this site is to supplement what you already know about the billing process so that you will have the well-rounded knowledge that is needed to: 

  • Know that a claim has been coded correctly.
  • Know how to bill a clean claim.
  • Recover every dime that is due.

If you think this site holds the answer to every question that you have about coding, billing or reimbursement – sorry that’s not possible.  The way a claim is created and billed will vary greatly; by plan, by benefit, by insurance carrier and even by procedure code and unfortunately, health insurance processes and procedures are ever-changing.

This means you can never stop learning.

Some of the information on this site reflects our personal opinions, observations and experiences. Please use this site as yet another source of information.