When you receive a medical bill for your doctor visit, medical tests or hospitalization, do you feel like you need a tutorial to decipher the bill?
In this country, we lack standardization in regard to what information a patient bill should include (https://www.nytimes.com/2015/05/03/sunday-review/the-medical-bill-mystery.html). According to Healthcare Business and Technology, 80% of medical bills contain errors (http://www.healthcarebusinesstech.com/medical-billing/).
To manage your medical bills, start with saving and filing your Explanation of Benefits (EOBs). These forms come from your insurance company, and help to explain the services, the cost of services, what the insurance company pays the provider and the balance that the patient owes. When you receive your medical bills, examine them closely and compare the bill with the EOB. It is a good idea to save this information (medical bills and EOBs) for several years in case insurance companies have problems with their systems. I recently received a bill for services provided almost two years prior. The bill was a result of a “system error,” and I actually had a zero balance, so it helped that I saved the information in order to resolve the problem.
What common errors are found on medical bills?
1. Duplicate bills for the same service: Be sure to examine the list of services and check for duplication on the individual bill. Also, compare your new bill with those on file and make sure there is no repeat billing for the same service. Sometimes duplicate bills come and they do not say “second notice.” This happens often: billing services are commonly outsourced and there are “glitches” with the system. The system sometimes starts “spitting” out multiple bills for the same service (http://www.healthcarebusinesstech.com/medical-billing/). People often don’t notice (especially if the co-pays are small amounts) and end up paying for the same service twice.
Here are a few unethical (if not illegal) issues with duplicate billing and overcharging:
A. Although, the overpayment might be resolved, it could take weeks, months, and even years to get the refund. Meanwhile, the providers have the money and are making interest on it. We might not think that a $20 co-pay amounts to much, but it does when you multiply that by the thousands, or tens of thousands.
B. Another process that occurs with overpayment is that some providers simply apply a credit to your account and do not notify you. This has happened to me, as well as others I have interviewed. I had to call the billing department to request that the refund be sent to me. Think about it: What happens to those credited accounts when the patient moves and forgets about the account, changes providers, or dies?
2. Billed for a cancelled test: Sometimes bills are submitted when tests or appointments are cancelled. Be sure to check the itemized bill, and if you do not recognize having had the test or service, contact Billing to correct it.
3. Incorrect or incomplete information: wrong patient, wrong insurance company, wrong account numbers, wrong personal information (address, date of birth, etc.). Make sure all information is correct on your medical bill. Be on the alert for incomplete information as well. I have received bills that simply said, “Balance forward” with absolutely no other descriptive information anywhere on it.
4. Upcoding: All services, drugs and procedures are assigned a code for billing and tracking purposes. Each one of them has an associated cost. They are called Current Procedural Terminology (CPT). Upcoding can be done knowingly or unknowingly.
Unknowingly: This occurs when the wrong CPT code is entered by mistake, which translates into errors with billing. You’ll want to contact the billing office and report the error. If it is necessary for you to check the meaning of the codes (perhaps you do not have a clear explanation on your bills), the AMA has the following site to search the explanation of the codes:
Knowingly: If a provider misconstrues the codes in order to receive more money from the payer, this is fraud. If you need to report a potential upcoding, refer to the link below. There are providers who have been investigated for upcoding and have been fined millions of dollars. Upcoding is an extremely costly healthcare fraud. “Between 2002 and 2012, it cost publicly-funded medical assistance programs an estimated $11 billion dollars.”(Https://Www.Whistleblowersinternational.Com/Types-Of-Fraud/Healthcare/Upcoding/).
5. Unbundling: This is more difficult to decipher, but some procedures are “bundled” and should not have separate fees. If you see several sub-charges that are related to one procedure, inquire about this process.
6. Balance billing: This is where the EOB helps to decipher what you owe as the patient. If you are billed for other charges besides the co-pay, again inquire about this process.
7. Incorrect quantity: This happens often with hospitalizations and surgical procedures: If you see an unusual amount of medications or supplies, such as dressings, investigate this.
What do we need in order to dispute medical billing errors?
If you suspect fraud, report this to Health and Human Services (HHS) Office of Inspector General (OIG): https://oig.hhs.gov/about-oig/about-us/index.asp The Health Care Fraud and Abuse Control Program (HCFAC) is under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services acting through the Department's Inspector General (HHS/OIG). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse.
It takes some extra time, but examining your medical bills is worth it.
Charlotte Michos is a Clinical Nurse Specialist who values personal-centered care and serves as a Healthcare Consultant in helping others make informed decisions.
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