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An insider's guide to medical bills

Medical billing errors are all too common. Here's a former pro's best tips for avoiding common billing mistakes.

By MSN Money Partner Sep 10, 2012 12:31PM

This post comes from Gerri Detweiler at partner site on MSN MoneyWhen Heather's daughter developed a reaction to an immunization, she took her back to the doctor. She knew she should not have been charged for the second visit. After all, she spent 14 years working in medical billing and understood that the follow-up incidental visit should have been covered given the circumstances.


Image: Insurance Money (© Comstock Images/Jupiterimages)However, the claim wasn't properly coded, and she found herself in the shoes of many of the patients she had helped over the years, trying to fix a medical billing mistake.


Heather, who is leaving the field to pursue an accounting career, says that medical billing snafus are all too common. But don't automatically blame the billing clerk, she says. Oftentimes, mistakes are made before the account even gets to the person responsible for submitting the claim to the insurance company.


"The number one problem I (saw) was not that the patient had not provided proper billing information, but that front-desk employees failed to update the system," she explains. As part of her job, she would research records and call patients before she sent accounts to collections and often discovered a mistake that allowed her to properly bill the insurer.


The problem may be getting worse, she worries, as medical practices consolidate into larger ones. She believes medical billing staff members with credible expertise are often underpaid and underappreciated, but at the same time she understands the frustration of the patients. "They have jobs, lives and pay substantial premiums, only to be made responsible for billing errors made by medical billers," she wrote in a comment on a previous story about these problems.


She shares these tips for avoiding a medical billing nightmare:


Verify your file contains up-to-date, correct insurance information. The person at the front desk is often juggling multiple tasks and may not carefully check to make sure your information is correct. So while you are waiting to see the physician, you can double-check yourself.


"Ask your (medical) provider for a printout of the 'patient profile information screen' from their system, which should list all of your insurance information," she recommends. Make sure it's 100% accurate. One insurance company may have hundreds of addresses and departments listed for processing claims, she explains, and if the claim isn't submitted to it correctly, the claim may be kicked back.


Don't assume that because you are still with the same insurance company everything is the same. If you received a new insurance card since your last visit, you'll want to make sure your file is updated. The billing address or other key information may have changed, making it important that you update the information. Keep the corrected and dated patient profile information screen for your records until you have verified the bill for that date has cleared. (Post continues below.)

Watch your mail. After you have seen the provider, watch for an Explanation of Benefits statement from your insurance carrier that will list your financial responsibility. You should receive it within 30 to 45 days after your visit. If it doesn't arrive, contact your provider immediately to find out why your insurance company has not been billed.


When you do receive the EOB, you may find it confusing. If you do, call your insurance company and ask it to help you decipher the EOB.


If you believe there is a mistake, you'll want to contact the provider's billing office. When you do call, don't be surprised if the person you speak to within the billing office doesn't fully understand what's going on. "You are not usually talking with the person who actually does the billing," she says. "The person who you are talking with is likely a customer service representative, and they may know very little about the process that has taken place or needs to take place."


If you don't think your problem is being properly handled, Heather recommends that you:

  1. Call the provider's office and ask for the exact amount of the services provided and a breakdown of the individual charges.
  2. Call the insurance company and ask if it has a receipt of that claim.
  3. Then ask the insurance company if it will contact the provider on your behalf.

Don't let them "balance bill" you. Medical providers who participate in insurance networks agree to a fee schedule, which is often changed and updated each year as a part of the provider's "recredentialing process." Along with the contract, the health care provider is given a fee schedule that shows what the allowable amount for each procedure (designated by a CPT code) will be, Heather explains. By accepting this agreement, the provider in turn agrees not to bill to the insurance carrier's customers more than the allowable amount.


For example: A "doctor's visit 99213" is a pretty standard office visit. The physician charges $110, the insurance carrier allows $58, and there may be a $30 co-pay. The insurance company will pay the provider $28, the patient pays $30 and the provider contractually must write off or, as they call it, "discount" the remaining $52 from the patient's account.


"This is more critical with expensive procedures like lab work, X-rays and the like," Heather says, where charges may run in the hundreds or even thousands of dollars.


In addition, providers who are contracted with specific insurance companies must typically file a claim with the insurance company within 90 to 120 days, depending on the insurance carrier's contract. If they fail to do so, they can't hold the patient responsible for those charges. If a provider tries to "balance bill" you, either for an amount it is supposed to discount, or because it failed to bill in a timely manner, enlist your insurance company's help.


"Bottom line: Health care providers sign contracts with insurance carriers to develop their patient pool, and patients unaware of the provider's contractual obligation can unknowingly be held responsible," Heather says.


Plan ahead. Because hospital bills in particular can be very large and confusing, it's a good idea to meet with the billing department in advance to go over your insurance information. At that time, ask for a list of expected procedures and a ballpark estimate of the anticipated costs. This is typically done for self-pay patients; insist upon the same for you. Then call your insurance company to also go over with it what's covered and what is not. "You are the insurance company's customer," Heather insists. It should have a fee schedule that shows what it will pay.

If you ended up in the hospital unexpectedly and are stuck with a confusing or large bill, make an appointment to visit with the billing department afterward to go over the charges, to get answers to your questions and to make payment arrangements if possible. Hospitals know some patients have no intention of paying, so making the extra effort to show you want to resolve your bill can pay off.


If it sounds like a lot of work, it is. But it can be worth it if it helps you avoid a collection account on your credit reports for the next seven years.


In Heather's case, she ended up paying the additional co-pay rather than fight it. She knows that if she can't fix a mistake, it must be that much harder for the average patient. "There needs to be a place for patients to go where they have an advocate," she says. "If you've paid your insurance and provided your information, you shouldn't be at their mercy."


More on and MSN Money:


Sep 19, 2012 1:07PM
I had a baby back in April. I just now recieved an itemized bill after asking for it several times. They billed me $5 for an over the counter iron pill. I recieve 2 a day for 3 days. You can buy a 100 count bottle for less then $5. Lesson learned I will now be bringing my own Iron pills, anti gas pill, Prenatal vitamins, and stool softeners.  They charged more for the over the counter products then they did regular prescription pain killers.
Sep 19, 2012 2:40PM

Just recently, I had to get bloodwork done, on the next visit to get the results, I was told that there was an error in reading the results, so I had to get another lab done...none of which insurance would cover, so I had to pay again for erraneous results...and to top it off, I was to get 10% off of my bill if I had paid within 30 days...I paid within 2 weeks and never got my 10% refund.  This is just my latest example in this freak show called "health insurance"

Sep 19, 2012 2:39PM
Heather is correct-YOU ARE THE CUSTOMER-don't forget that when you deal with doctors and insurance companies. I have been a medical biller for over 15 years and I do the best I can to help the patients understand the overly complex process of billing. I am always happy to review the explanation of benefits with our patients and to make sure at the end of their treatment that all their claims were processed correctly before the patient pays their portion. Most doctors understand that the economy has made it difficult for most people to pay in a lump sum and they will accept a payment arrangement, if they do not, find another doctor. Most insurance companies have very user-friendly websites that can give you an estimate of your costs. Never hesitate to ask questions or ask for help understanding your bills.
Sep 19, 2012 3:08PM
medical system is a joke - wait a month to see your PcP - wait a month to see a specialist - oh now you're dead cause you had something we could have fixed 2 months ago... YAY health care.
Sep 19, 2012 1:17PM
I am a medical biller/coder,  Heather fails to mention that front desk personnel can give a patient a copy of their demographics that includes insurance information ask the patient to review, make any corrections and sign the document, seems that all too many patients will sign the form even though their insurance info is incorrect. Many patients fail to bring their insurance cards, rarely do they think to bring money for a copay, when they see the doctor they present with exact symptoms then complain when their insurance does not pay 100% for their preventative care visit and don't care when you explain that coming in for an upper respiratory problem or UTI does not get coded as a preventive visit.  Not all problems stem from the provider side.   These are just a few samples of problems the provider must deal with
Sep 19, 2012 3:49PM

"If you don't think your problem is being properly handled, Heather recommends that you:

Call the provider's office and ask for the exact amount of the services provided and a breakdown of the individual charges.
Call the insurance company and ask if it has a receipt of that claim.
Then ask the insurance company if it will contact the provider on your behalf."

AND number 4.

They are NOT going to adjust your bill.  They don't care if it is a mistake.  PAY it whether it is your or not.  They will send you to collection and ruin your credit.  Then you can't buy a car or a piece of candy.  Your insurance rates go up...oh yes they do...they run your credit.  And then you can't find a job because they check your credit too.  ENJOY THAT!!!

Sep 19, 2012 3:09PM
and thats the problem bill, HAVING TO PAY FOR A MEDICAL VISIT EVEN THOUGH YOU HAVE INSURANCE - its like seriously WTF
Sep 19, 2012 3:12PM
and of course they'll let you pay later - when you're ripping somebody off are you really gonna stop them from paying? we all know the system charges us honest people more to make up for the  dishonest people that dont pay.
Sep 19, 2012 4:04PM
$125 A WEEK FOR HEALTH INSURANCE, $2500.00 DEDUCTIBLE PER PERSON, HIGH CO-PAYS.  And on top of it all, most items don't even count toward our deductible,  No wonder so many people cite MEDICAL BILLS as a reason for bankruptcy.  It is getting impossible for a family to even afford proper medical care.
Sep 19, 2012 3:57PM

Part of Obamacare will be that even "more CPT codes will be needed in order to help weed out fraud in billing errors".........SERIOUSLY?????........This will only add to the headache of the people that actually submit claims to the insurance company from the Dr's office......if you think it's confusing now just wait.........ICD-9 coding is going to get worse also, as this is the code used to determine why a particular lab test is ordered......there may be 20 different reasons a Dr might order a lab test and a different ICD-9 code for each reason ( which is a decision Dr's do and should be able to make) but the insurance companies (driven by profit) may decide (based on someone's opinion that is NOT  a board certified Medical DR.) that your Dr. didn't use a code that they think showed the proper necessity for the test and completely deny payment on an expensive test........however if your insurance company decides not to pay at all YOU are responsible 100%......GET THIS STRAIGHT....if  the insurance Co pays the Dr. a price that is less than what the Dr. charges for someone without insurance because (with their contract and the hudreds of thousands of people they insure in that contract) the insurance Co. says it increases the VOLUME of patients for the see the Dr. gets less money per patient but a higher volume of income....but if they decide to not pay at all because someone did not code an order for a test correctly...YOU are responsibel for 100% of the bill at the price the Dr. would NORMALLY charge........or you can spend weeks or months fighting with you insurance Co on the phone while constantly getting transfered from one person to another because nobody knows who is responsible for the billing error and in the end you will usually be told that the mistake must have originated in the Drs. office (or at the Hospital)........HEALTH INSURANCE IS THE GREATEST SCAM ON EARTH........Ask anyone who has Blue Cross.   

Sep 19, 2012 3:27PM
Don't have a problem, am on Medicare and supp. no care  in the world, screw the hospitals they can't sue me, cuz I have nothing
Sep 19, 2012 4:17PM
I guess this is the thanks we get for putting in an honest days work, EVERYDAY of every week of every year of our lives.  We get to pay for our own insurance and copays and overinflated bills, so some people that are too lazy or unwilling to get off their a$$e$ can get health care for free.  Mind you I am not stating this toward people that are legitimately disabled or unemployed due to circumstances beyond their control.  But there are so many people out there just living off the backs of all of us that work our lives away, and they seem to be better off than I am in the end, I may not have much but atleast I am getting it honestly.
Sep 19, 2012 4:13PM
Any Credible Dr. should NEVER have to worry himself about a patients ability to pay a bill......the MOMENT that money becomes a motivating factor for a Dr. and has the ability to influence them to treat one patient  in a different manner than another we have all lost our basic human emotion of caring for one another in the best way possible......unfortunately Insurance Co's and HMO's make this something that every Dr' has to stress about by consistently lowering the mount paid to Dr's (who agree to be in their Network and their "contracted pricing to them") thereby depleting the quality of care at it's deepest levels simply because they are PROFIT DRIVEN and don't really care about YOU THE PATIENT.  There is a Dr. in my area who was so disgusted with the system that he opened an office as a General Practitioner ....does NOT accept any form or type of insurance and you can visit him for a $40 fee......last I heard he was having to turn away patients because he could not handle the volume.
Sep 19, 2012 5:23PM

Beginning with enrollment in October 2013, individuals and employees of small businesses who are uninsured can go to the exchanges to compare private health plan options across four levels of coverage -- bronze, silver, gold and platinum -- and purchase coverage.

The exchanges must ensure that each health plan offers a sufficient number of providers and meets other minimum standards. To participate in an exchange, an insurer must offer at least one "gold" and one "silver" health plan.

Each state's exchange must also maintain an up-to-date website with comparative health plan information; maintain a toll-free, consumer call center; and fund a "navigator" program to assist individuals and families with obtaining coverage. The exchanges are also the vehicle for people who meet certain income thresholds to qualify for tax credits to reduce their premium costs and federal subsidies to lower out-of-pocket expenses.

The federal government is offering premium assistance in the form of refundable tax credits to people with incomes up to 400 percent of the federal poverty level ($44,680 for an individual and $92,200 for a family of four in 2012) and out-of-pocket spending caps on covered services


I want to see a "definition" of what bronze, silver , gold and platinum coverage means and what will be included in each on.....this smells like more " profit driven" healthcare.......tell me please,when it comes to healthcare,  why is one person more.deserving of "better" care than another one just because they happen to have more money?

Sep 19, 2012 4:38PM

Let us also never forget that Dr.s "practice" medicine......most are extremely competent in what they specialize in after years and years of education, residency and experience but God forbid they make a "mistake"   When you factor in the Dr.s cost of his (mandatory at whatever price the insurance Co. wants to charge) Malpractice Insurance  it's no wonder they want to be as thorough as possible when diagnosing YOU THE PATIENT.  I want my Dr. to be able to order whatever test HE thinks are necessary in my diagnosis instead of being TOLD BY MY INS CO. what he can order and expect to get paid for or how long he can keep me in the hospital (if necessary..  which can be determined by my Ins Co.) ....once again the PROFIT DRIVEN INS COs. are telling my Dr. how to treat me using MONEY AS THE MOTIVATING FACTOR.  By far any practicing Dr's biggest expense is the cost of his malpractice if my Doc makes a mistake  I don't sue him...I get the privilege of suing his Malpractice Ins Co......which will definitely deny my claim until it can be proved that he was actually at fault....which brings us to another problem.....try getting any hospital to provide you with any kind of necessary proof that they or a Dr. on staff at that hospital actually made a mistake (see how far they will distance themselves and deny a mistake) if it is not glaring and obviously their fault........oh bring in the Legal Eagles who do not care one way or the other because they simply will not take a case that they know they can't win...........This is our wonderful health care system in the US

Sep 19, 2012 4:30PM
It gets even more fun with twins.  I received an Explanation of Benefits for one of my children at a local hospital.  That child has never been to that hospital, so they have absolutely no record of name, DOB or anything else.  When I called the insurance company to say that there must be a mistake, they told me it must be the hospital's fault.  When I then explained that the hospital did not even have any records of the named patient, but rather that the patient's SIBLING had been to the hospital on the stated date and receiving the stated treatment, only then did the ins co research further into the matter.  Turns out that the local ins. co's claims processing department - to which local providers are required to submit claims - was randomly choosing one of the two siblings for EVERY CLAIM.  This was messing up preventive care billing and coverage, immunization coverage, deductible limit fulfillment, and a host of other issues.  The non-local ins. co had to go back through all bills for the entire year and recalculate everything to get it straightened out.  Even now, I still see EOBs coming across as "duplicate bill", even though I know it isn't.  Somewhere at Empire Blue Cross, there is an employee who should be fired or jailed, depending on whether this is simply negligent or worse, intentional behavior to avoid payment.
Sep 19, 2012 5:28PM

"In states that do not create an exchange, the federal government has the authority to do it for them."


Wow...does the state get charged for this Forced Government Plan???



Sep 19, 2012 3:02PM

Newly revised medical billing statement:


2 Asprin - $1.00
Nurse to administer - $3.00
Obamacare Tax - $275.95


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