For most of us who have health insurance (employer group, individualcoverage, VA, Medicaid or Medicare), chances are we never see thebill from the doctor or hospital. It is sent directly to theinsurer for payment. Isn't that nice!

Or is it? About six weeks later we may get a print-out from theinsurer stating the bill amount, what the insurer paid, and what weas the insured may still owe. A few weeks later, a bill from thedoctor or the hospital arrives with a very short “pay by” date.This includes any deductibles, co-pays and, more importantly,amounts in excess of what the insurer covered. Too often it's quitea bit. For what?

The bill never says and the statement from the insurer is likelyto show only codes with some vague references. You saw one doctorfor perhaps 15 minutes, but you get bills from six differententities all charging for that same short visit. That's how thegame is played – you don't see what is being charged for your care,and the service providers (physicians, clinicians, X-rays,pharmacies, therapists, pathologists and specialists) each feed offthat same insurance. Did you actually receive the care for whichyour insurer was billed?

The role of the adjuster

Several evening news magazine programs have run features on howmedical providers through the insurers are ripping off the system.It happens in other types of insurance as well: bodily injuryliability, medical pay or workers comp, but there is a difference.Supposedly, somebody is looking at all of those medical bills andthinking, “Hey, how does this relate to a broken arm?” How manyX-rays of that arm were needed, and was a MRI or CAT scan reallynecessary? We call it “medical bill auditing,” but apparently thefolks in the healthcare/medical insurance business never heard ofit.

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