If you get a bill you didn’t expect months after visiting the doctor, it can be confusing and upsetting. Didn’t you already pay this? Why has the cost changed?

Although uncommon, health insurance claims sometimes need to be adjusted. Reasons vary. Sometimes there’s an issue between your doctor and your health insurance company, or an update that’s changed what your insurance pays. Often, it isn’t anything you did or didn’t do.

Let’s talk about claims adjustments, how they work and why they happen.

What a claims adjustment is and how it works

When you go to the doctor or other health care provider, they send a medical claim to your insurer for payment. During this billing process, your insurance company will review the claim, determine what your insurance plan covers and pay what your plan owes for covered services.

Typically, claims process without any problems, but occasionally they need to be reassessed. This is where a claims adjustment may come in.

Your insurance company might request more information to process the claim. If it finds that an adjustment must be made, your claim will be fixed. When your health insurance company re-reviews and modifies a prior claim so the payment amount is correct, a claims adjustment is filed. They’ll usually notify you of a claims adjustment if it affects the amount you owe.

HealthPartners members can contact Member Services for any questions about health care claims

Common reasons for claims adjustments

There are different reasons why your claim might be adjusted. Here are some common situations that may cause an insurance company to reassess a claim.

Health care provider changes

Your doctor or provider’s costs change

A claims adjustment can happen when your provider adjusts how much they charge for services. Rest assured, these price changes aren’t random, they’re pre-planned. Most in-network providers’ contracts with insurance companies renew at the beginning of each calendar year. During this process, prices can change. However, this time period may vary. For instance, HealthPartners sometimes renews provider contracts on July 1. Renewed contracts, whenever they occur, may result in a claims adjustment if a member received care before the new fees were active in billing systems.

Your provider needs to correct or update their bill

While most providers have quality checks in place at their clinics, they sometimes accidentally bill for the wrong service or procedure, such as a 45-minute doctor’s visit rather than a 30-minute visit. Depending on your insurance company, these issues may be identified quickly or may involve a bit of back and forth between your doctor and insurer.

At HealthPartners, if billing code errors are found in a member’s claims submission, providers generally update the information by sending us corrected codes. This may cause the claim to be re-processed based on the new coding and can result in a cost adjustment.

Providers generally have up to 12 months to send changes to a health plan if they find an error. This is why a member whose claim was adjusted might receive unexpected bills for care that took place a year ago or more.

Member and policyholder changes

A policyholder doesn’t provide accurate information

When you or someone on your plan gets care for an injury, the details of how and where that injury happened can affect how your health insurance will pay. For example, if you were injured in a car accident and have auto insurance, your auto insurance policy may be responsible for paying a certain amount of your medical bills before your health insurance kicks in. Because of this, health insurance companies might ask for additional information when processing a claim.

At HealthPartners, we sometimes ask members to return a Coordination of Benefits (COB) form to Member Services (via mail or their online account) to get additional information before we process their claim. A COB form tells our claims specialists if a member has another form of insurance (like auto or home) that should pay first for certain types of claims. Without this information, the claim may be processed incorrectly, and a claims adjustment may be needed later.

A policyholder appeals a claim

Members sometimes choose to appeal a claim with their insurance provider, most often when they believe a denied payment should have been paid. If the appeal is approved, your claim may be adjusted to align with that decision.

A policyholder’s plan termination isn’t fully processed

A claims adjustment can happen when a claim is processed after plan coverage has ended. For example, if your insurance coverage ends on Feb. 28 and you go to the doctor on March 3, your doctor might unknowingly bill your cancelled insurance plan. If the plan termination hasn’t updated in the insurer’s systems, the plan may pay the claim. In that case, your claim will be adjusted since you no longer had coverage under your health plan when you received treatment.

A newborn isn’t yet added to parental insurance

Newborns begin receiving health care services the moment they’re born. However, a policyholder parent has a window of time to add that newborn to their insurance coverage. If the insurer receives claims for a newborn who hasn’t yet been added to a health plan, those claims will be denied. Once the child is added as a member, the insurer will re-process the claims and adjust them to apply the policyholder’s plan benefits.

Government regulators or employer changes

The government changes regulations or payment rates

Sometimes an institution like the Centers for Medicare and Medicaid Services (CMS) or a state’s Department of Human Services (DHS) updates its payment rates or regulations around payments. When this happens, it can instruct insurers to make changes retroactively. This can cause claims to be adjusted for members who are covered by government-sponsored plans, such as Medicare and Medicaid.

In addition, many payment rates for services received by people not covered by a government plan are set at a certain percentage of CMS’s cost. If CMS changes health service pricing for Medicare beneficiaries, that could have a ripple effect for those with non-Medicare plans and claims adjustments may occur.

Your employer makes a benefits change

When an employer makes a plan benefit change mid-year, claims filed for health care services received during that transition may need to be adjusted. Fortunately, this occurrence is uncommon, since many employer-sponsored plans can’t be adjusted throughout the year.

Insurer data system errors

Although it doesn’t happen often, insurers can make mistakes. When that happens, your insurance company will fix the error as quickly as possible. By law, insurers can correct these errors up to 12 months after the original claim was decided.

At HealthPartners, a significant portion of our claims processing is automated, but there is still room for human error. This is especially true when members get care from non-contracted providers, since our systems are not set up to receive their claims automatically.

Our claims specialists are trained to work effectively and efficiently, and we do our best to avoid errors. We also do quality checks regularly to identify and resolve errors quickly.

Fraudulent charges

Sometimes, an insurance provider will pay for claims that are later determined to be fraudulent. An example is a claim for care that was never provided. In this case, the claim would be re-processed and denied retroactively.

As a patient and member, you can help spot fraudulent charges by always looking at your Explanation of Benefits (EOB) when they arrive. If you see something that doesn’t add up, such as a reference to care from a provider you didn’t see or for services you didn’t get, call your plan’s member services.

Do claims adjustments happen across all types of coverage?

Claims adjustments can happen across many types of coverage, from private plans to government programs like Medicare and Medicaid.

Some claims adjustments can also impact a member’s Flexible Spending Account (FSA) payments if an FSA payment was made for a claim that’s later readjusted. Contact your FSA provider to understand what you need to do if that happens.

How claims adjustments can impact a health plan member

A claims adjustment sometimes means you owe more or less to your health care provider than first thought. This typically results in an additional bill or a partial refund from your provider. It can also change where you’re at with your health plan’s deductible or out-of-pocket maximum.

If you have questions about how a claims adjustment impacts your plan balances or what you owe a provider, contact your plan’s support team.

How to know when your claim has been adjusted

There are two common ways for a member to learn of a claim’s adjustment. You might receive an unexpected bill or a refund from your care provider. Or you might receive a new EOB from your health plan via mail or in your online account that lets you know an adjustment has taken place. In both instances, you can call your member support team for more information. They’ll be able to tell you the details behind why your claim was adjusted.

For HealthPartners members, if the claims adjustment doesn’t change a member’s out-of-pocket cost, we don’t send an EOB. For example, if you paid a copay for a doctor visit and a claims adjustment occurred that increased the amount HealthPartners owed the provider for that service, you won’t be alerted, since it doesn’t change how much you pay.

What to do if you’re confused about a claims adjustment

If you get a bill from a doctor that surprises or confuses you, or you get an EOB that says there was an adjustment made, don’t panic. It’s time to give your insurance provider a call. At HealthPartners, that means reaching out to our Member Services team, so we can walk you through the details and handle any concerns you may have.

Preventing or avoiding claims adjustments

Most claims adjustments happen for reasons out of a member’s control. However, your involvement in the claims adjustment process is important. Sometimes your insurance provider will request more information, and responding in a timely manner can go a long way.

Getting your care from in-network providers is also a great way to protect yourself from unexpected costs. Insurance companies have contracts with in-network providers that protect members from being charged for certain extra costs. Some insurance companies, like HealthPartners, also require in-network providers to automatically submit claims for members, which reduces delays and the risk of mistakes.

Still have questions about claims adjustments? Our Member Services team is here to help

At HealthPartners, we do our best to process claims quickly and correctly the first time, but occasionally, claims require adjustments when new information becomes available. If you’re a HealthPartners plan member and you have a question about a claim, our Member Services team can help.