Bill Review Services Not Available

Please Note:  There are times when our team will make exceptions and may be able to complete a service that we don’t normally offer however, this is decided case by case and depending on the nature of the request.  

Completing claim forms on member's behalf

Currently, this service is not included as part of our bill review services offered.  We do not have the bandwidth necessary to complete claim forms.  We can obtain a blank claim form on behalf of our members and provide instructions but the member would be responsible for completing, signing, and submitting the claim form directly to their insurance carrier for processing.  

Writing appeals on member's behalf 

Currently, this service is not included as part of our bill review services offered.  We do not have the bandwidth necessary to complete 3rd party appeals on behalf of our members.  Generally, most providers will initiate 3rd party appeals on behalf of their patients whenever they receive adverse determinations.  However, if a 3rd party appeal is not initiated by the provider we can contact the provider to inquire if they would be willing to appeal on the member's behalf.  If the appeal is not submitted by the provider, we can provide instructions to our members on how to submit an appeal and offer some additional guidance but the member would be responsible for writing, signing, and submitting the appeal directly to their insurance carrier.  

Negotiate with providers or lower patient responsibility 

Bill review does not negotiate fees with insurance carriers and providers to reduce out-of-pocket expenses for patients because we do not have any leverage to negotiate with them. Additionally, when a provider is part of the insurance carrier's network, the patient's financial responsibility is determined by the contractual fee schedule that is on file with the insurance and the cost they are allowed to bill the patient for services. Also, the reason why the member may have a higher out-of-pocket cost is that they could have a high deductible plan, and must satisfy their deductible before the insurance plan begins to pay for services. To provide helpful information we recommend that they reach out to the provider directly to arrange a payment plan and/or apply for financial assistance to verify if they are eligible.

Set up payment plans or apply for financial assistance on the member's behalf

The Bill Review Team is not able to set up payment plans or apply for financial assistance on behalf of the patient, the provider requires that the responsible party contact them directly therefore, we recommend that they reach out to the provider directly to arrange a payment plan and confirm their eligibility for financial assistance.

Audit accounts

Currently, this service is not included as part of our bill review services offered.  Requests of this nature require a lot of time to complete and we do not have the bandwidth necessary to complete requests of this nature.  Additionally, we lack access to certain information necessary to complete audits.  Therefore, we recommend that our members reach out to their insurance carrier directly to request a claims detail report if they have concerns about when they met their deductible and out-of-pocket maximum. In addition, if members believe they have overpaid for a service with their provider or hospital, they should request an itemized statement which should reflect all charges and payments posted to their account.  If they determine discrepancies they should ask the provider to conduct an audit of their account to confirm any overpayment and determine their eligibility for a refund.

Complete bill review request for services prior to employer group launch dates

Due to contractual obligations, we do not process bill review requests for services that occurred before the launch dates of the employer group even if the organization had the same insurance carrier/TPA and plan benefits when they launched with HealthJoy. Additionally, if they changed insurance carriers and have different plan benefits we will not have the member's previous insurance information on file in our system therefore, we have no way of accessing plan benefit information and cannot review that information to determine accurate processing of claims based on their previous plan benefits.  

Advise providers how to bill for services

We cannot advise providers on how to bill for services. If a claim is denied due to erroneous billing such as an incorrect diagnosis or procedure code it is the responsibility of the provider to review those codes and, if applicable, submit a corrected claim to the insurance carrier with the updated codes in accordance with the medical billing and coding guidelines. Most billing providers are trained in medical billing and coding and should have the expertise to determine which codes are eligible for billing and which are not.

Advise what procedures, services, or medications should not have been rendered or administered

Our Bill Review Team is unable to guide members regarding the procedures, services, or medications that should have been performed or rendered.  Our team are not medically trained professionals therefore, we must refrain from offering professional medical advice to our members. Any services that a member receives should be discussed directly with their medical, dental, and pharmacy physicians/providers.

Provide definitive/accurate cost for services

Definitive costs for services cannot truly be determined until the service has been rendered and the claim has been processed by their insurance carrier.  Therefore, we cannot provide accurate costs for services offered but we can provide an estimate based on information obtained from their insurance carrier, or provider or by utilizing an app such as https://www.mdsave.com/. The member can also request a cost estimate from their insurance carrier and/or the service provider. Additionally, many insurance companies offer a cost estimate tool per their online portal. The member may also contact HealthJoy via the HealthJoy app and our HCC call and chat teams should be available to assist members with cost estimates for specific services

Mail documents

Bill review representatives operate remotely, therefore, we do not have the necessary tools/resources to mail documents to our members or on our member's behalf however, we can email or fax documents. 

Complete thorough bill review requests without sufficient information

In order for the Bill Review team to complete thorough bill review requests we must have sufficient information.  Please see this document to understand what sufficient information).  If we lack sufficient information we will not be able to obtain the necessary information from the insurance carrier and will not be able to complete the member's request.  

Add members to insurance policies

Bill Review is unable to add members to insurance policies or modify an effective date with the plan. This process is exclusively managed by their employer's HR Department and usually can only be updated during the open enrollment period or if they have a qualifying life event such as having a baby, or the death of a spouse. 

Complete checks and balances for payments made to providers that are not reflected on the EOBs

Members often reach out after receiving a copy of their EOB to inquire about being billed twice despite having paid upfront for services at the time services were rendered. We clarify that an EOB is not a bill; it serves as an explanation of how the claim was processed, and advise that their EOB will never reflect any upfront payments they may have already made to a provider because the insurance carrier does not keep track of any patient payments to providers. Therefore, members need to compare the EOB with the billing statement they receive from their providers to ensure that they did not overpay.