Insurance: What Happens After You Leave


Author: The Editor

21 Dec, 2022

Understanding the Health Insurance Claims Process


What Happens After you Leave?

Understanding the health insurance claims process is complicated enough for the health professionals providing you with care, let alone the poor patient without an inside knowledge of a particularly opaque system. In this short article, we hope to de-mystify understanding the health insurance claims process sufficiently enough that when you next receive a statement or EOB – Explanation of Benefits – it does make at least some sense.


Before you Arrive

So, what happens after you leave in fact starts before you arrive, at least in well-organised practices, and is designed to support what happens after you leave to ensure it goes smoothly. At Integra, we typically do the following when we know you are coming:

  • Call the insurer or go online via their portal to check your benefits
  • Calculate what is likely to be covered, partially covered or not covered in each category (sickness, wellness etc) to that the doctor can discuss the impact of care or diagnosis decisions on costs, especially if it involves lab tests etc

This is a complicated process and it is best done quite close to the visit as information can change and is never ‘set in stone’ even if we check. We have to make sense of amount of cover in different categories, and whether you have a deductible (an amount you have to pay before insurance starts paying) and/or co-pay (a proportion of the bill you are required to pay as specified in your policy).

All insurers and policies are different!

The better we are at getting it right, the higher the chances of you being charged the right amount on check-out and when the claim is processed, the results matching up to the expectation. At Integra, we are careful with this because every time there is a mismatch or change, it creates extra work after the claim is processed and often confusion for the patient. And who likes getting another bill, right? But it’s not a perfect process and if an insurer processes another claim after we have checked, it can change the status on your account.



And then there are precerts (or pre-certification as they are officially called). This is a process in which we have to get pre-authorisation to do something or order something, or the insurance company can deny it, or only partially pay it, when we claim.

Most routine care does not require this. It tends to be required when diagnostic tests are over a certain value or for specific items or procedures. Almost all hospital care requires pre-certification, although if something is an emergency, there is a default agreement that even where required, it is done afterwards. A preterm delivery would be an example of this – it might happen suddenly and you can’t hold up care waiting for an insurance company to open up on a Monday morning!

Again, each insurer and policy is different in its requirements.

If a doctor knows why you are coming and believes that what they need to do or order requires precerting, we will do this in advance. Frequently we don’t until the visit itself, which can often be to ascertain what is wrong anyway. In this case, we can try to precert at the time, or sometimes certain diagnostics, for instance, have to wait until we have gone through this required process. Whereas it might feel like an interuption, it is also designed to avoid a patient being landed with large bills they weren’t expecting. It also prevents doctors from engaging in work when benefits or cover levels have been exhasuted (when this happens, the patient can find themselves liable).


Whilst Here

So, you visit, are checked in and go to see your doctor. As the visit unfolds, the doctor, and sometimes the nurses too, are adding special codes to your visit on our Electronic Patient Record system. Typically, they are using two types:

  • ICD-10 Codes – International Classification of Disease (and 10 is just the version we are using)
  • CPT Codes  – Current Procedural Terminology

The former tells the insurance company what we are addressing e.g. a mole that might be a melanoma, and the latter explains ‘how’ we are addressing it and there could be many of these e.g. one for the consultation, one for a technique called dermoscopy, one for any bloods that are taken, one for each lab test ordered etc.

When the visit is finished, the doctor completes this and ‘signs’ off that this episode is ready for billing.

Generally, at this point, you visit the front desk and they examine your bill and request any payment on your part e.g. co-pay of 20%. The fees that are used are called Cayman Standard Fees for most things, and come from a schedule called the SHIF – Standard Health Insurance Fees – which is set through Government and has not changed for 17+ years (yes, that’s 17 years of inflation in costs but not increases in fees!).


After Leaving – Understanding the Health Insurance Claims Process

So, this is where the fuzzy logic goes on behind the scenes and when we say ‘fuzzy’ that’s because it is not a set singular process and it often has variations in it. Last start with the simple version, where our dilligence in pre-checking your insurance pays off and the claim outcome is as expected. We’re going to say your bill was $150 KYD, and you paid $30 KYD co-pay on checkout. Here’s what happens… smoothly:

  • We generate something called a CMS 1500 (or Form 1500), which pulls in your insurance details, your details, the ICD-10 codes, CPT codes and some demographic information
  • Sometimes, we need to manually find some additional information
  • We then use this information to either complete a claim on the insurers portal system, or fill a claim form and submit by email, in each case sometimes attaching or uploading documents, along with the charges and how much we took from you at the time
  • This is then processed in due course by the insurer (the best ones in a few days, some much longer)
  • The insurer then outputs two things: payment of the remaining $120 KYD outstanding and something called an EOB (Explanation of Benefits)

Because Integra has so many patients, it is rare that this final stage is for a single claim. Normally, we will receive a batch payment and an EOB with many claims listed on it (sometimes amounting to 10 pages of data). This needs to be processed patient-by-patient too, so the payment is attached to your Integra account and clears the oustanding balance.


This is quite a common occurance and often happens because they may have received a claim from another doctor before ours arrives that uses up remaining benefits in a category. So, in our example, let’s say they pay $100 of the outstanding $120 and the EOB says that $20 was not paid, with a reason for it. This is where a healthcare practice gets back in touch with you for the remaining amount.

At Integra, we are fairly pragmatic and most of our patients are coming to see us a number of times during each year. So, if the amount is relatively small, we put a note on your account to collect this next time you are in. We may drop an email to let you know its owing. If it is larger, we let you know and you can either phone us to pay, or we will give you a call to take a credit card payment or similar.

Sometimes, we disagree with the insurers interpretation. You mostly don’t get to hear about this! In these cases, we challenge (nicely) the insurer on your behalf, so that by the time we get back in touch with you, we’re confident the amount is final and correct.


Another common scenario is where the insurer decides they want more information before agreeing the claim. It can happen for many reasons, such as them wondering if a different ICD-10 code is necessary or whether we have used the best CPT code for an item (there are many closely related CPT codes and different insurers view which one to use differently sometimes).

These claims are initially ‘denied’ by putting them into a holding process whilst we go back and forth with requested information. This usually involves the nursing team here providing the requisite information and sometimes the doctor providing additional information too. The output of this process (hopefully!) is that everything is resolved, and the normal process is resumed. Occasionally, it means they only pay part of a claim and tell us you own some more, and very occasionally they may deny a claim, in which case the whole bill becomes due personally. This is pretty rare and in most cases we have had multiple discussions with the insurer on your behalf.


Other Possibilities

As the SHIF has not been updated for 17+ years in terms of fees for a particular CPT Code, some practices add an extra fee, which the insurance company will not pay as it is above SHIF. At Integra, we are fortunate to have be able to use our scale to avoid this by seeking efficiencies elsewhere.

Virtually all practices have within their standard terms that anything not paid for by the insurer becomes a patient personal liability. As we have said, we tend to fight on your behalf until it is clear we can get no further through the insurer. When you receive your statements from your insurer, we believe it is vital that patients check what was billed to their insurer matches what was quoted at check out. As you can see, there are humans involved at both ends in every stage of this process and so this helps pick up genuine mistakes.

If a practice has made a mistake in their billing and coding process, again perfectly possible, ethical practice is to call you to explain before submitting a revised higher claim. The process is called upcoding, and there are legitimate reasons why it happens occasionally (mistakes, for instance, or at the advice of an insurer), but also it holds the potential to be abused too, so you checking is a vital step in ensuring the whole health system remains robust and correct.


More Information

At Integra, where excellence and integrity are two of our core values, we are always happy to explain bills in detail or explain how we think an insurer reached the conclusion they did. You should never feel embarrassed to ask and we are always delighted to take the time.

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