Advance Beneficiary Notice (ABN)
Some services are not payable by Medicare or other insurance companies. If your physician orders these services, you will be asked to sign an ABN. The ABN is notification that you understand that payment for the listed services will be your responsibility, if Medicare or your insurance company denies payment. If you do not sign the ABN, the test should not be performed. If you decide to receive the service but refuse to sign, the registrar will indicate on the ABN that the “Patient Refused to Sign,” and you (the patient) will then be responsible for the bill.
ABN For Experimental Procedures/Tests
You will also be asked to sign an ABN for lab, infusion and radiology services your commercial insurance company considers experimental. Rather than deferring treatment, you should ask your physician if an alternative test /infused medication is available. This is especially important if you have Highmark BlueCross BlueShield of Delaware, as many employers in the area have coverage through a BlueCross BlueShield plan from another state, and that state’s medical polices may be different from the Highmark BlueCross BlueShield medical policies. You should ask your physician to call your insurance company’s home BlueCross BlueShield plan to confirm the test will be covered with the diagnosis on the order and that their medical policy does not consider it experimental.
Many insurance companies require an authorization to be issued prior to tests or procedures being performed. Without an authorization, the insurance company will not reimburse Bayhealth and it may be your responsibility to pay the bill depending on the contract between your insurance company and the hospital. Your physician will request the authorization from your insurance company. When authorizations cannot be verified at the point of registration, you’ll be asked to sign a letter accepting financial responsibility or you may opt to postpone the test until authorizations are verified.
A percentage, determined by the payer, of the patient’s total charges that the patient is responsible to pay. The health plan usually pays the remaining portion of charges.
Coordination of Benefits (COB)
A method of integrating benefits payable under more than one group health insurance plan so the insured person’s benefits from all sources do not exceed 100 percent of his or her allowable medical expenses.
A fixed fee that the subscriber must pay for his/her use of specific medical services covered by his/her plan.
Explanation of Benefits (EOB)
All insurance companies are required to send you an explanation of benefits form, which explains what they are paying and shows the amount you owe. It usually shows total charges, allowable charges, non-covered charges, the payment, deductible and coinsurance (when applicable), and any notations to clarify any of its actions. The amount you owe should be the same as the hospital bill.
Charges for services rendered to you that were omitted on the first bill. They are not charges being added to the account for late payment.
Medicare Explanation of Benefits (EOB)
Medicare sends summaries of their payments (EOB) to the patient on a quarterly basis. These summaries may show a different amount than the hospital bill. This difference is created by the hospital’s agreement with Medicare. Medicare payment is not based on the hospital charges but on Medicare’s established payment schedule. Medicare determines the amount that is the patient’s responsibility. This amount should correspond to the amount due from either the patient or your secondary insurance. Please keep in mind that if Medicare doesn’t pay for a hospital service, often the secondary insurance company will also not pay for that service. There could be more than one EOB from Medicare per visit. Inpatient stays will usually generate a Part A and Part B EOB.
Medicare Take-home Drugs
Drugs that are usually self-administered by the patient, such as those in pill form or that are used for self-injection, aren’t normally paid by Medicare (or other insurance companies). However, there are some self-administered drugs that are explicitly covered by Medicare.
Provider Based Physician Practice
Outpatient departments of the hospital where services provided at the facility are considered hospital services. Unlike a private office setting where you receive one bill, you may receive two bills; one for the physician and one for the hospital. In summary, you may incur a coinsurance liability to the hospital that you would not incur if the facility were not provider based.
Recommendations made by your physician as to where to go for treatment. Referrals don’t guarantee payments by the insurance company. Please see “Authorization” above.