Your Claims Post Visit Adventure
Spoiler Alert: It’s complicated
A few years ago, one of our adult children ended up in the hospital. The care was excellent, but the paperwork that followed was not so much.
Months later, a bill arrived, thousands of dollars, marked past due, and completely unexpected. The kind that spikes your heart rate before you even open the envelope. You know, the type of bill that makes you wonder if you accidentally purchased an MRI machine while you were there.
They almost paid the bill, even though they couldn’t afford it.
Paying would have meant cutting back on rent, food, or gas. Like many people, our child assumed that if a bill shows up, it must be right.
Yes, they likely would have been reimbursed once the provider or payer corrected the error. But that’s not the point. Most people can’t afford to front thousands of dollars and wait weeks (or months) for a refund.
How often are bills paid, not because the patient agrees with them, but out of fear?
Fear of debt. Fear of collections. Fear of damage to credit. Fear of getting stuck in a mess they don’t know how to fix.
And behind the scenes? Sometimes it’s not even a care decision. It’s an administrative error. A missed code. A timing mismatch.
This was our case, an administrative error. (We’ll get to those details in a minute)
Here’s the thing, this shouldn’t take someone with 25 years of experience in healthcare to catch it. This kind of knowledge, how claims work, where things go wrong, and what patients can do to fix it, shouldn’t be limited to “insiders” in the industry.
This isn’t just red tape; it is your care, your coverage, and your money. So let’s take a quick look at what happens.
Behind the Scenes: What Happens After Your Visit
In earlier posts, we talked about how the roles of patient, provider, and payer shape the system, and how miscommunication between them can cause confusion, billing issues, and frustration.
So what happens after you leave the doctor’s office? Let’s walk through what’s going on behind the scenes.
Let’s say you have a cough and a fever and need to see a doctor. You make an appointment, you go to the doctor, get care, and go home.
Your appointment triggers a behind the scenes process that looks something like this:
(Please note, this is not a picture of every touchpoint in the process, but provides the key handoffs)
The Claims Process Flow:
Appointment Scheduled: You (the patient) check in, receive care, and go home
Provider Documents the Visit: The provider performs an examination, orders any tests, and records what was done during the visit in the medical record
Coding Completed: That documentation is turned into standardized codes (What was done = procedure codes, and why it was done = diagnoses)
Claim Created: Those codes are assembled into a formal claim and submitted to your insurance for review
Claim Reviewed: The payer reviews the claim for coverage, network status, prior authorizations, and medical necessity
Payment Decision Made: The payer approves, denies, or adjusts payment, and sends that response back to the provider
Payment Posted by Provider: The provider receives the payer’s decision and applies the payment (or denial) to your account
Bill Sent to You: You receive a bill for any remaining balance (if applicable)
Each step matters, and each one depends on the previous step working correctly.
A mistake at any point, whether it is a typo, a missing code, or a delay in the claim submission to the payer, can cause a ripple effect that can end in a balance sent to the patient that shouldn’t exist, or a denial (non-payment) that is confusing.
Our real-life example - what went wrong
So let’s go back to our real-world example.
Our adult child received a bill stating that they had a balance due, but it was unclear what the insurance had paid.
In our case, two critical steps failed:
Step 6: Payment Decision
The insurance company processed the claim and paid several items. Some were flagged incorrectly, such as when the doctor was marked as out of network, even though there were other visits for the same doctor and hospital that were paid (which leaves you scratching your head).
Step 7: Payment Applied to Account
Even when payment had been made, it wasn’t correctly applied to our child’s account in the provider system. From the provider's perspective, it appeared that the insurance had not paid anything, and they sent the balance to our child as a bill owed.
🎶 “And you may find yourself... with a large medical bill you don’t understand...”
“And you may ask yourself... well, how did I get here?”
(Yes, I’m quoting the Talking Heads. And yes, this is a very real lyric moment for many people dealing with the U.S. healthcare system.)
Let me walk you through the steps I took to figure this out.
Here is what I did:
I got authorization to access the insurance and provider portals on my child’s behalf
I requested a detailed, itemized invoice from the provider’s billing office for all of the services done
I downloaded every Explanation of Benefits (EOB) from the insurance company (I had it exported as a spreadsheet; anyone who knows me knows I love a good spreadsheet! I also color-coded it, obviously.)
I matched each billed item to what the insurance had processed (EOB)
I checked for any missing claims, incorrect denials, and services labeled out-of-network
I confirmed which claims were paid by the insurance and which payments weren’t applied
And here’s what I found:
The insurance paid claims, but the payment was not posted to the account at the provider (Step 7)
Some items were flagged as out-of-network incorrectly (Step 6)
A few claims hadn’t been processed by the insurance at all, possibly due to data issues or mismatches (Step 5 or 6)
How did I get it fixed?
I sent the spreadsheet with the details to the provider and requested
Payment be applied
Items billed (or rebilled) by the provider to the payer, for items that did not show as processed (e.g., if they didn’t show up on the EOB)
I contacted the insurance and requested that they reprocess the claims marked as out-of-network, providing examples of visits where the insurance had processed and paid claims for the same provider and hospital
No one was trying to be deceptive; it was a classic example of a breakdown in one of the system's steps.
But without this review, our child may have paid a balance they didn’t owe, just to avoid the stress of trying to figure it out and the risk of collections.
But here’s the thing….
I knew what to do because I’ve worked in the industry for years. I knew the rules and the system.
But these steps and this knowledge are not reserved for “insiders”; they can absolutely be used by anyone, especially with the right tools and some support.
This might mean:
Asking your provider’s billing office for a detailed invoice
Calling your insurance company to walk through an EOB with you
Or even just knowing what to say when something feels off
And yes, this might be where personality comes into play.
Are you the kind of person who loves solving puzzles?
Or the kind who would rather poke your eyes out than call a billing department?
Either way, the goal isn’t to make you a medical coder.
It’s to help you feel like you’re not powerless.
Why It’s Important
Even if you don’t want to dig through the medical bill line items, having some context and understanding of how the system works can help:
Ask the right questions
Spot red flags, issues, errors
Potentially steer conversations with your provider or payer
Because it’s your care. Your bill. Your money. And you deserve to understand what happened before you are asked to pay.
And if you’re on the inside of healthcare, working on product, technology, or operations teams? This understanding is so important.
Building workflows, automating processes, or backend logic, you are replicating the flow and understanding the handoffs (This impacts adding new tools, systems, or integrations)
You are automating handoffs between the payer, provider, and patient
You can spot errors, risks, and deliver the products you build faster
Build solutions that improve user experience and quality (and make a real difference!)
You can build smarter, more efficient, and user-friendly tools, including the use of Artificial Intelligence (AI) and Automation. The most effective healthcare AI isn’t only trained on data, it is guided by people who understand the real-life messiness behind these systems and codes.
Let’s Land The Plane
No one sets out to become an expert in medical billing (well, ok, I did, but that’s for another blog post). I believe a little bit of knowledge can go a long way. The more we understand how the system works (and why it works like that), the more we can shape it to work better. And maybe next time a bill shows up, you might say, “Wait…I know what to do.”
Quick Tips for Patients
Now, I know most of you are not thinking “I cannot wait to dive into this insurance billing paperwork!” but some quick tips upfront may help on what is to come after your visit.
When possible, understand what you are having done and your insurance coverage (obviously, this may not work for an emergency visit)
You don’t have to memorize your insurance policy, but understand where you may be using your healthcare benefits (e.g., office visits, what is considered preventative, and are there conditions for the preventative visit (or procedure) being covered?)
Ask your provider for a detailed, itemized bill (bonus points if it includes the procedure codes and diagnosis codes, it helps when matching up to the EOB!)
Note, this may be available through an online portal and may be available to export into a .csv or spreadsheet format
Download your Explanation of Benefits (EOBs) and match them to bills before paying
Note, look for a way to export to a .csv or spreadsheet format if that’s your jam
If something doesn’t look right, call your provider's billing office or insurance member services numbers (Don’t be afraid to call your provider or insurance, just start with “Can you help me understand this?”)
You don’t have to fix everything yourself—but a little understanding gives you the tools to ask the right questions
Quick Tips for Teams
Product and tech teams don’t need to dream in procedure and diagnosis codes, or be billing experts, but have to understand how the system works because it shapes the products, patient, provider, and payer experiences. It’s a huge advantage!
Know what happens between patient care, coding, payer review, and billing
Map the hand off’s, know who does what, from the front desk to coding, billing, and the payer process
Find ways where technology reduce friction or confusion
Get familiar with the vocabulary. Don’t assume that the teams know the difference between a claim, a bill, or an EOB (or what goes on them)
Include patients in your users (persona) sets even if they are not the primary user, your decisions will impact patient experience
Test with real scenarios, not perfect scenarios (use edge cases)
Build language in the systems that reflects common language and workflows
Be clear on the action happening, even if it is bad news (if a claim was denied, or the patient owes money, say it clearly, offer helpful steps)
Help build in action, not just understanding (are there places that someone can do something about it, while still following compliance and standards)
When your tools reduce confusion, they build trust and client retention
If you’re building AI, make sure it’s learning from workflows and people
Context, transparency, and accuracy aren’t nice-to-haves; they’re non-negotiables in healthcare.
📚 Missed the earlier posts in this series?
Catch up here: https://coviewconsulting.substack.com/
Why I Started CoView: Navigating Both Sides of Healthcare
Speaking the Same Language in Healthcare
Meet the Players: Patient, Provider, Payer
Cracking the Code
What’s Next: “This is NOT a Bill” – Understanding Your EOB
See you in the next post, where we’ll tackle the most misunderstood (and arguably most misleadingly labeled) document in healthcare: the EOB. Spoiler: it might say “not a bill,” but it still feels like one.
Understanding your EOB is one of the most powerful tools you can utilize as a patient or when building systems that serve patients.
Thank you for reading,
Bonnie
💡 If this topic sparked questions or curious to keep learning? This blog is part of our series and ties directly into our recent webinar
Speaking the Same Language in Healthcare. If you missed it, no worries, the replay is available and a handout.
Feel free to email me at bcoburn@coviewconsulting.com or send me a message on Substack or LinkedIn.
Note from the Author: This series is not a prep course for medical coding exams. It’s designed to help cross-functional teams in the healthcare industry work together more effectively. The skills you'll learn will also empower you to be a more confident advocate for yourself and your loved ones in your own healthcare matters.
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