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.
This post comes from Gerri Detweiler at partner site Credit.com.
When 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.
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 Credit.com 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:
- 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.
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 Credit.com and MSN Money:
- Why medical collections need an overhaul
- The complete guide to disputing credit report mistakes
- How to negotiate your medical bills
- What if you got hit by a bus?
- Survival guide for the uninsured
- 10 tips to save on prescriptions
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"
"If you don't think your problem is being properly handled, Heather recommends that you:
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!!!
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 Dr.to 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.
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?
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 insurance.......so 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 great......now 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
"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???
Newly revised medical billing statement:
2 Asprin - $1.00
Nurse to administer - $3.00
Obamacare Tax - $275.95
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