08:00 AM

Patient billing & insurance 101

When you get your car repaired, you receive a bill, pay the bill, then drive home in your fixed car. It’s the same for grocery shopping: you pay at check-out for the goods received. One bill. One payment. Transaction is complete. If only medical billing could be so simple.

There are many layers to health care (we’ll need more pages to cover it all) that influence your final bill as a patient. However, by understanding how insurance and medical facilities talk with one another about billing, we hope to shed a little light on why this process can be confusing and lengthy. As always, if you have any questions call your health insurance company or doctor’s office to check on benefits about a week before your appointment to confirm coverage and costs.



Book appointment, provide insurance info.

Pre-registration with provider, confirm financial responsibility and insurance benefits with payer.

Go to doctor/clinic for medical care.

Professional medical services delivered by provider as patient care.

Appointment complete.

Medical report coded, sent to payer on behalf of patient for reimbursement.

Patient receives Explanation of Benefits (EOB) from payer. This is not a bill.

Payer reviews request for payment (aka: claim) and decides if the claim is correct based on insurance policy.

Timeframe to this point is approximately 60-90 days.

Payer approves payment to provider or rejects claim. Errors or lack of information may start this cycle over.

Patient may receive a new/updated EOB or abill from medical facility.

Payer agrees to final payment (or not). Sends payment to provider/facility. Remaining costs billed to patient.

Any edits or delays to the flow may start the entire process and timeline over again. Each step is generally a minimum of 30 days for processing a “clean” claim and up to 90 days for those with errors or discrepancies related to coverage.

Tips to stretch your dollar at the doctor

Before you choose a new provider, it may pay off to ask these questions before your first appointment.

What’s your plan and payment?

What type of health insurance plan do you have? That will help determine your payment at time of service. If you have a high-deductible plan, you may pay in-full. If you have a co-payment, you will share costs with your insurance company. Know before you go.

Is your doctor “in-network”?

Selecting a provider that your health insurance already works with will likely lower your costs. Out-of-network providers will usually mean higher charges for you. Call your insurance company with the name of your provider to be sure.

Review your coverage.

What services are covered? For example, most dental plans cover two annual trips to the dentist, but they won’t cover any orthodontia work. You’ll may have to pay from your own pocket if you need or want braces. Checking ahead of time will ward off any surprises and unexpected bills.


Check out other frequently asked questions about patient billing at this link: https://www.krh.org/krhc/pay-bill/frequently-asked-questions