Illnesses, incidents and bills: what's the difference?
Editor’s note: To read previous articles in this series (beginning in the January 2019 issue of Heartfelt Magazine), visit our magazine page.
Illnesses, incidents, bills. If you’ve submitted medical bills to CHM, you’ve heard or read about one or more of these terms.
If you haven’t experienced medical problems—and we hope you never do—it’s still wise to read on. Doing so will make it easier for you if a health situation arises.
An illness is a diagnosis of an identified disease, injury or medical condition that may be treated once or multiple times (multiple incidents). CHM sharing limits are determined by illness. Members can receive up to $125,000 per illness in the regular sharing program and up to $1 million or more per illness by participating in the Brother’s Keeper program. (Brother’s Keeper sharing at the Gold level is unlimited.)
An incident is different from a diagnosis. An incident refers to testing or treatment, and multiple incidents can occur within a single diagnosis. An incident includes medical treatment or testing that lasts until one of the following occurs:
- the medical condition is cured according to official medical records;
- treatment is at a routine maintenance level; or
- you experience 90 days without any treatment for that particular condition (testing or treatment must be an eligible expense at your chosen level of participation: Gold, Silver, or Bronze.)
A single incident results from medical bills incurred from the first test to the last treatment before the doctor releases you to a regular, routine maintenance regimen. If 90 days pass and you receive no further treatment, any future bills (even for the same condition) will be considered a separate incident. CHM personal responsibility amounts for the Silver and Bronze programs are per incident. (The Gold program shares 100 percent of bills for any medical incident in which the total of eligible costs exceeds $500; learn more here.)
Examples of illnesses and incidents
Example 1: Diabetes is an illness that can be treated at a maintenance level but can flare up and create an incident. The incident (medical bills related to the flare-up) has a definite start and end date; however, the illness can last throughout a lifetime, resulting in multiple incidents.
Example 2: Your knee hurts so you go to the doctor, who orders an MRI. After viewing your test results, he diagnoses you with arthritis. He gives you a cortisone shot and your knee soon feels better. The diagnosis of arthritis in your knee is an illness. The medical examinations, testing and treatment you undergo is a single incident. Two years later, your knee starts to hurt again. You return to the doctor, who says your arthritis has flared up. He gives you another cortisone shot. After two weeks, you go back because it still hurts. He tells you that you need a knee replacement and schedules the surgery. You undergo surgery and physical therapy. After a few months, he gives you a clean bill of health. This scenario describes a second incident within the illness of arthritis in your knee.
CHM’s definition of an itemized medical bill is one that contains:
- the patient’s name
- the date of service
- the place of service
- the procedural (CPT) codes
- the itemized charges
A bill is categorized under a particular incident, which falls under an illness and diagnosis.
In the previous example describing the diagnosis (illness) of arthritis, there were two separate incidents because the patient received treatment for arthritis on two separate occasions. Likewise, within each incident there were separate itemized bills.
(The following describes bills shared by CHM’s Gold program; Silver and Bronze members should consult the CHM Guidelines for guidance because not all bills listed below are eligible for sharing through those programs.)
In the first incident, the patient would likely have incurred separate bills from the initial doctor’s office visit, the hospital or clinic performing the MRI, and from the second doctor visit during which the cortisone shot was received.
In the second incident that occurred two years later, there would likely have been separate bills for:
- the doctor visit
- the second doctor visit
- surgery (bill from the hospital or clinic)
- surgery (bill from the surgeon)
- surgery (bill from the anesthesiologist)
- pre- and/or post-operative prescriptions
- physical therapy (multiple bills)
- third doctor visit (follow-up and declaration of clean bill of health)