By Ron Wiens 

Healthcare billing: Why does it have to be so complicated?


March 8, 2023

When I walk into The Grocery Store and grab a diet coke and pringles, and the cashier rings up $4.00, that’s what I pay, and I pay it before leaving the Store. Same thing when I take my truck in for an oil change. I pay the posted price of the oil change and if the mechanic finds something else that needs fixing, I get a quote of what it’s going to cost before anything else is done to my truck. If I approve the repair, the work is scheduled with the mechanic and the repair gets done and then I pay the quoted price.

Not so with paying your healthcare bill. Why? Well, that’s complicated. To really give a good answer, I’d have to start back in the 1950s when most people were still paying for healthcare out of pocket and it was relatively “cheap”. Then in the 60’s, the Medicare and Medicaid programs were established by Congress. This brought insurance coverage to millions of seniors (Medicare) and those with very low incomes (Medicaid). For those working, one could expect their employer to provide a good quality health insurance program offering low or no deductibles and co-pays.

Initially, there was little concern about the cost of healthcare. Medicare, Medicaid and insurance carriers typically would pay 100% of whatever was charged by a hospital or provider. So, the incentive to healthcare organizations and providers was to significantly raise its prices every year. By the 1980’s healthcare costs were rising twice as fast as general inflation. Since then, both government and private insurers have continually introduced new programs and tactics to help curb these costs. Managed Care organizations sprouted up everywhere and started dictating where, when and what would be paid of a patients stay at a hospital or a visit to the doctor. Medicare introduced managed care with the Medicare Advantage program.

The bottom line? Healthcare billing and payment of services got very complicated. Healthcare organizations must now know all the intricate details for each government and private insurer program, each of which has its own payment policies and procedures to follow. Fortunately, there are computer software programs to assist hospitals and providers in keeping track of these always changing requirements, yet even these programs can be challenging at times. It can take weeks for insurance companies to pay and sometimes the payment is incorrect or the claim is denied, which adds significant time delays and staff hours in getting the claim processed correctly.

For Big Sandy Medical Center, this has been a struggle for a long time. When I arrived here a few months ago, there was a significant backlog in processing old claims, and still is today. In the meantime, though, the billing staff have made significant strides with improving the current billing process to ensure accurate and timely statements are sent out. So, what about the old claims? One of our staff has stepped up to provide an audit of each and every account that is over 6 months old. This will be a daunting task and could take several months, yet it needs to be done ASAP. I’m excited and encouraged about our progress so far and I ask for your patience as we get our house in order.


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