I admit it.  When driving on a highway, I don’t drive the speed limit.  I always drive 10 miles per hour over the posted speed limit.  Why?  Mainly because over time this is what I have learned I can get away with.   Now if I see a police car sitting in a median, I will slow down to the posted speed limit.  But once I am comfortably past him or her, I speed back up.  What will it take to make me drive the posted speed limit?  I think it will probably be a police officer pulling me over, telling me that I am in violation of the law, and giving me a speeding ticket.

Figuring out what we can get away with is human (and business) nature.   Health plans and providers may push things just a bit when they think no one is watching. We are not saying that they are intentionally taking advantage of the system to see I don't drive 55what they can get away with when it comes to the costs and coverage of healthcare. Most times health plans and providers are pushing the limit without realizing that is what they are doing.

For example, a physician office or a hospital generates and submits bills electronically.  The staff in these offices do not review each bill before it is sent to a health plan or to a patient for payment.  They have learned over time that a certain percentage (hopefully a high percentage) of claims are billed from their computer system without errors or problems.  They are willing to take the risk that 5-10% of the bills will have errors and cause future issues because 90-95% will be ok when they are billed.

Health plans work in almost the same way when processing the claims for payment.  They know that by contract or by statute, they have time limits for processing claims for payment.  Some health plans do not closely follow these time limits unless a healthcare provider or a patient let’s them know that they are taking too long in paying the claim.

It’s important that you become the “police officer” sitting in the median when it comes to your medical expenses.  Review your medical bills carefully to make sure they seem appropriate for the care you received.  Review the Explanations of Benefits you receive from your health plan to make sure they are processing and paying your bills according to the terms of your insurance policy.

Be the enforcer, not the victim.