E-mail updates
Follow on Twitter
Subscribe to RSSNEW YORK -- Yvonne Dailey opened a medical bill and was left scratching her head about why her insurance company didn't pay for the emergency treatment she received while suffering an asthma attack.
She knew the bill had to be the result of an error. But unlike most consumers who open a medical bill sent due to a mistake, she knew where to look and what to do. Dailey, 43, runs a medical billing company in Toms River, New Jersey, and she was able to see quickly that the explanation of benefits from her insurer showed the nebulizer treatment she received to help her overcome the attack was rejected. Why? Her diagnosis was incorrectly listed as "anxiety" instead of "asthma."
She reported the error to the insurance company, physician and hospital and was able to get the diagnosis code corrected. And the costs -- about $1,500 in all -- were then covered.
Medical billing is rife with errors like this. A recent study by the American Medical Association found that while billing accuracy has improved, one in 10 bills paid by private health insurance have mistakes. And with many more Americans headed toward insurance coverage in 2014 when many of the main provisions of the Affordable Care Act take effect, that just increases the possibility of error.
All involved want to minimize billing mistakes, says Dr. Kaveh Safavi, managing director of the consultancy Accenture's North American health industry practice, but they still occur because from the medical side, it costs money to correct errors.
So, what's a consumer to do? "You should really scrutinize your bills and ask questions," says Dailey.
It isn't easy or simple, but medical billing experts, including Joshua Greenberg, chairman and president of HealthCPA -- a healthcare finance consumer advocacy firm -- say consumers need to understand their ever-changing insurance coverage.
Here are some suggestions they have for preventing mistakes and spotting them when they do happen:
- Be sure your provider has accurate, up-to-date information on you, Safavi says. A mistake with something as simple as a middle initial or date of birth can lead to all sorts of billing problems. If you're admitted to a hospital, the same issues can multiply -- with so many separate bills being generated from a single stay -- so patient advocates recommend you try to get a friend or family member to help check paperwork while you're being treated.
- Understand your insurance coverage. Knowing your deductibles and co-pays -- things you should check before you receive treatment (if possible) -- will help you spot when something might be amiss, according to the Healthcare Billing & Management Association. For instance, your insurance might cover 80 percent of the "usual and customary charges" for an out-of-network visit. That isn't going to be 80 percent of the total bill if the provider charges more than that industry standard, Safavi notes.
- Keep track of what services you have received and what you've paid and keep the records, says Greenberg. Bills can come months later and it will be difficult to rely on your memory.
- When you receive an "Explanation of Benefits" form from your insurer, don't just file it or toss it in the trash. Many in the industry, including Greenberg, note the importance of that document since it explains what is being paid for and what isn't. If it isn't being paid, that's the main opportunity to find out why.
- Don't just pay a bill because you received one. Be sure that what's on it are items that you or your insurance company haven't already paid, Dailey says. Use your explanation of benefits to check against bills you might receive. Also, note that some medical practices will send out statements that look like bills prior to any insurance payments being applied, Safavi notes.
Dailey says she has seen that a lot of times. "I find that the seniors don't review their statements," she says. They'll get a follow-up bill that crossed their payment in the mail and "they'll pay it again," she says.
In order to resolve errors, the key is to act quickly, those in the industry say. Bring the mistake to the attention of the hospital - or, if you receive multiple bills from multiple providers - contact all of them. A phone number for the billing department will typically be on the bill if there is an issue to be raised, Dailey says. Having documentation available can make a big difference, says Medical Bill & Claim Resolution co-founder Sunni Patterson. It will allow you to demonstrate that you've already paid, were charged twice or received a bill that you shouldn't have.
In addition, there are a growing number of companies like HealthCPA and Medical Bill & Claim Resolution that offer services to consumers to help them resolve medical payment issues. And there are other, newer entries like Simplee, which offers a free online platform where consumers can have all of their medical bills and insurance payments collected online and allow software to try to discover mistakes for them.
When you appeal a bill or are told that a problem is being corrected, follow up to be sure that it has, HealthCPA suggests. And whenever you receive a medical billing notice or benefits explanation, ask about anything you don't understand. "Patients really need to get involved and they don't," says Dailey.
Leave a Comment:
Welcome to the REAL world of private insurance in the US. Hospitals and insurance companies have no real incentive to get things right if the charges are in their favor so we are all screed in the process.
A couple of points that the article missed:
1) There have been numerous studies of billing accuracy, mostly aimed at saiving money for the hospital, the physician, Medicare ir Medicaid themselves, or just to understand how they occur. The bottom line is that way over 90% of all billing errors benefit the for-profit institution or the physician. If the errors had been the result of random errors it would have been 50% in favor of the biller and 50% in favor of the patient. This is one way that physicians and hospitals use to abuse the system, especially health care insurance carriers and Medicare and Medicaid. Floating a few fraudulent charges among hundreds of legitimate ones is easy. I'll bet you dollars to donuts that the Copeland gal that was just discharged from hospital in Augusta, with no feet, was charged for those stupid hospital clogs (that run around $25 a pair) or bootee socks (that run around $6 a pair.) When you put items like that on the bill of a girl with no feet, it is fraud and it happens knowingly and constantly by hospitals and physicians who think they are entitled to more and more and more of those wonderful patient dollars.
2) For an individual to check their own bills is extremely difficult. If you don't have the time or are too sick to inspect your bills for errors, you can find an expert to check them for you. Medical-billing advocates either charge an hourly fee, from about $50 to $175, or they work on a contingency basis, earning a commission of 15 percent to 35 percent of the amount they save you. If they take a percentage, you don't pay a dime unless they lower your bill, which makes them highly motivated to do just that. It's a little tricky to find a medical-billing advocate because you may see them listed several ways online or in your local phone book, including as claims-assistance professionals, medical-claims professionals, or health-care claims advocates. You can find one through Medical Billing Advocates of America, which has 65 across the country. Keep in mind that most of their work will be done by phone, so they do not have to be nearby.
Chris-749391 - The majority of billing errors occur due to human error. It makes no difference if it's a for-profit or non-profit organization, billing errors occur constantly. Some providers are better than others at billing correctly the first time. I've had to deal with both crappy and not so crappy provider panels.
It's a serious pain in the a$$ to get your billing corrected, if you even notice the error in the first place. It takes hours making phone calls etc. trying to rectify the error(s).
Hummmmmmmm ... As a reasonably educated person it seems that I (and everyone reading this) should be able to understand a hospital bill ...I can't!
Why? .... because ...by creating confusion, they can get by with charging you almost anything!
Can you think of any other service that can effectively charge what ever they want for their services?
This is the natural result when there is a "Third Party Payee" for services and the most inflationary element of health care! If someone else is paying the bill, who cares what it cost or if the bill is fair and reasonable?
Or ...whats the restraining factor from going to the doctor or emergency room for every stubbed toe?
I insist on "Prepaying" my cost on hospital since my only insurance is Medicare, only to find that after a hospital visit to being bombarded with bills from various associated providers: Anesthesiologist, pathologist, labs, etc. for services rendered .... finding that my advance payment wasn't even a drop in the bucket to the total charges! If we took our car into a repair shop & they charged us in that fashion, we would scream like stuck pigs!
It seem s that hospitals make their billing as difficult as possible ... I stopped wondering why .... after dating a wonderful nurse that was in charge of a rehabilitation unit for a major hospital chain... who constantly was in dispute with the hospital bean counters, about patient care ... It's all about money and how much they can get from Medicare or the insurance companies .. not about practicing medicine! Bye the Bye ... after spending her life in the medical field, she left her job .... she couldn't take it..
Medicine is in a crisis at this moment .... it's a crisis of greed, and it's not going away until the people of this nation address the long term economic issues created by insurance & "Third Party Payees" effects and the "greed" factor that comes with the territory!
OBXRon-people make mistakes. A blanket accusation over something like this is ridiculous. Doctor's have terrible handwriting and medical coders are often left to decifer what is actually on the paper. If they code it wrong, or make a typo when entering the code, things can be rejected. If you think hospitals are telling their medical billers to improperly code things, you're nuts. Hospitals want to get paid. Just coding something wrong and billing the patient won't guarantee payment. The only payment guarantee would be to code correctly so the insurance company does get paid. This is HUMAN ERROR! Nobody's perfect.
@wkdwytch,
When people make "honest" mistakes, the chances are exactly 50/50 of that error being in your favor. This is not what studies have found --- in real life the errors are over 90% in favor of the biller. In fact, they have found that over 3% of all Medicare and Medicaid claims are fraudulent (not just a case of transposed numbers or omitting a field.)
No one would buy a car the way we buy health insurance. But there are people who make a very good living from finding "honest mistakes" on medical bills and then taking 25% of the amount of the errors for themselves. They know that every time a patient gives them a bill to check that the patient's suspicions are a great indicator that they will make some money.
I would like to see legislation that imposes treble damages in the case of these "mistakes."
It should be the job of the receptionist/accounting/medical billing specialist to code bills properly, not the consumer's. Most of us have no experience about coding and what it means nor how to investigate, and most of us don't have the time to do so. Instead of getting consumers angry and having them waste their time (and money, paying something that insurance DOES cover), they should get it right the first time.
And when the patient gives the doctor the wrong date of birth or id# or insurance policy how is that the fault of the doctors office?
@Genenut,
Actually it is the "doctor's office)'s)" fault a patient gives "the wrong date of birth or id# or insurance policy."
In an effort to curb identity theft, the Federal Trade Commission in 2007 unveiled what they called the Red Flags Rule." The Red Flags Rule requires all creditors to collect social security numbers, government-issued picture ID's and other pieces of personal information to prove the borrower is who he or she says they are. If a borrower does not not have the required documentation, that raises a red flag.
Originally, doctors and other healthcare entities were included in the lists of creditors who were required to collect all that personal information, because medical identity theft, including health insurance information, is growing exponentially. But those providers fought the rule, focusing on the fact that they do not consider themselves to be creditors as a credit card or mortgage company might be.
Enforcement of the Red Flags Rule was to begin in 2009. However, in 2010 it was decided by Congress that healthcare providers would be exempt from the Red Flags Rules under huge pressure from the AMA. It appears that they felt that too much scrutiny on medical billing would not be a good thing.
However, most doctors, hospitals and other health care entities in the interim started collecting SSNs and pictures of picture IDs in preparation for enforcement of the Red Flags Rule before it was withdrawn. They know that if they have trouble getting paid by a patient, they may use that SSN and picture ID to help collect what is owed to them.
You have to remember that the for-profit medical industry is the most litigous in the world and the medical industry is the very quickest of any sector to turn people over for collection. There was recently an article about using debt collectors to go to patients' bedsides and try to set up collection procedures before any care is even given. (The article noted that often the patients are not in a position to understand what is going on and are often intidated by the bill collector implying that if the patient does not "cooperate" that treatment will be withheld. This is a more common practice than people think.
And bankruptcy in this country is largely driven by the for-profit medical industry. Over 60% of all bankruptcies are caused by unanticipated medical bills and of those 60%, 40% (or 24% of the total) had acceptable levels of medical insurance.
And when the patient is a child that has wrong info? Because dad or mom gets the kids mixed up or gives a wrong ins card?
You are not going to win this one. It is not ALL the doctors fault. They are not omnipotent. In all patient bills of rights is the RESPONSIBILITY of the patient to ensure their info is correct at the time of service.
It would help if you could actually talk to a live person when calling with questions instead of having to deal with an automated answering machine - often with NO option of getting a live person for your question. Customer service in those agencies is often in very short supply.
I checked my bill from an ER visit and found that I had been charged for an Oxycontin script that I never recieved. I'm allergic and cannot take it. I called and had a meeting with the administrators and found that one of the nurses on duty that night had forged and filled a script in my name. Nice one. At first they said it was an honest mistake and would just take it off my bill but I felt there was something fishy.
Read your bills and statements, even if you don't have anything to pay and then go after anything unusual. Hospitals will bill you for stuff you never received just to make money.
Welcome to the secret dirty world of medicine...you know the one where we all pay for everyones healthcare needs...by cost shifitng the uninsured onto our backs
I'm all for prohibiting those with no insurance from shifting their bills onto the rest of us...I'm with the teabaggers that we need to stop covering people who don't have insurance...let a few kids die and we;ll see some real reform in this country...
@Renee,
I would also point out that Medicare Part D (enacted by Bush) has a mandate as well. The moment you become eligible for Medicare Part A (which is free and can only be opted out by opting out of Social Security entirely (while still having to pay the payroll taxes) you MUST sign up for Medicare Part D.
Now we have to remember that Medicare Part D was written by "legislative consultants" employed by the for-profit drug industry and the minutes from these meetings and even the visitors' logs for the White House are still being withheld on claims of "executive privilege." You know, that Part D that increasedeveryone's prescirtion costs by changing from UCR to MSRP.
If you do not sign up for Part D the instant you are eligible, and you ever need it in the future, you must pay a fine of $5,000 plus your Part D premium goes up 1% for every month that you waited to sign up. There is no limit, there is no cap, there is no way to appeal the fine, and there are no exceptions. And it cannot be construed, as with AHCA as a "tax" since it is collected by the SSA by withholding it from your Social Security checks and Medicare payments.
I did not take Part D for three reasons: a) it is crappy coverage, b) I can get the drugs far more cheaply than the co-pay by simply getting them from Canada, and c) my wife has Blue Cross Blue Shield that incldes vision and dental benefits that Medicare does not have. So I get my coverage through her. At this point to start using Part D, I would have to pay $5,000 and my Part D premium would be 43% more than the listed rate.
So I guess when Republican think tanks came up with a mandate, it was okay.
So I guess that when Romney did in Massachusetts, it was okay.
So I guess when George W Bush put a mandate in Medicare Part D, it was okay.
But if Obama did it, it is a sign of the Apocalypse. Or maybe it is just a trailer trash way of avoiding saying that they hate the fact that a Black man is President and they lack the cohones to come right out and say it. Otherwise they would have been complaining about it back when it was 100% a GOP idea.
Actually Chris you know FAR less than you think.
Because you have CREDIBLE drug coverage through your wife's blue cross policy you are exempt from the penalties at this point.
If you drop the blue cross policy and do not pick up another policy or buy part D at that point , then when you sign up for part d later on you will be subject to the 1% penalty.
There is also a penalty based on how long you were without drug coverage. That varies based on the amount of time you are without coverage.
There is no set 5000.00 fine for not having coverage.
Might I suggest reading the 2012 Medicare and You booklet or calling 1-800-Medicare to find out the FACTS about your health coverage instead spouting very wrong mis-information.
One doctors office I go to continually charge my old insurance company for my visits,,,,,I have talked to the accounts receivable dept. on three different occasions about this,,,,,My old insurance co. denies these charges, rightfully so,,,but something about this smells fishy,,,If it happens again I am prepared to tell them I will report them to the state health board,,,,,hopefully that will work.
ultimately one should be responsible for one's bills by keeping track of incoming and outgoing expenses as they arrive.
And both the doctor's office and the insurance companies stand to gain by screwing the patient.
@Trace,
What is a code 92119? Don't know? Why is it that you can't keep track of the codes since you claim to be responsible for all "incoming and outgoing expenses"? In fact, mostly nobudy knows enough to check a bill with all the proper information at hand.
There isn't just one billing code, but a bunch of them. They include but are not limited to:
I seriously don't think that you have any idea what you are talking about. I had a knee replaced several years ago and there were over 8,000 individual charges.
It is a lot like buying a car. The first thing they do is make you sign a paper saying that it isn't their fault if the car doesn't run. Then you start getting bills from steering wheel manufacturers and oil suppliers and seatcover makers and people who assemble the parts and for every lug nut individually and the thousands of other parts that go into a car and the hundreds of hours that go into building it. So you get a bill with thousands if items such as "3250 limber spring" and "gondo holder" (both legitimate car parts) and for the labor of different machinists and assemblers. But finally you get the car --- it may not run and you have to pay all these bills with thousands of items before the car dealer turns you over for collection ant tries to be the first to force you into bankruptcy before other creditors can tear you to shreds. And often you're in baknruptcy court before you even find out the final price of the car.
Would you buy a car the way you buy health care? I thought not. Do you think that you should be responsible for things that are encoded so as to keep you ignorant? I doubt it. All this crap about personal responsibility is oftan just like your statement --- crap.
And you dont know nearly the @!$%# you think you do Chris.
there are ICD-9 codes , these are diagnosis codes. ICD -10 is not valid yet, its still being worked on. Its just the next version of ICD codes. Like windows 8 is the next version of windows.
Then there are CPT codes. These are procedure codes. Sometimes they have modifers on them, like they only took an x-ray of your RIGHT leg. They would put a modifier on the cpt code to indicated the right leg.
All insurances including Medicare use them. There are no medicare billing codes. They use ICD-9 and CPT codes on thier bills too.
Taxonomy codes are codes that describe the provider as a hospital, family doctors, free standing clinic, etc. Its the same taxonomy code on every bill that provider sends out everytime. Like your paycheck stub always has your SSN on it.
Dental CPT codes wont be on your MEDICAL bill. Dental services are provided by a dentist not a medical provider.
NDC codes are assigned by drug makers for thier drugs. They are specific to the prescription drug.
DRG codes are diagnosis related groups. They only appear on in-patient claims (acute admission to the hospital) . They are based on the diagnosis codes and procedures. All insurances use them , not just medicare.
And my bill from the mechanic is often quite long since it details EVERY part they put in or take off my car. And he doesn't let me have my car back until I pay for it IN FULL. The medical provider lets you take yourself home and pay for the services later.
it is to one's advantage and responsibility to keep track of one's own services received and the ability to ask questions and correct errors instead of passively looking at a bill. sure there are many codes but you should know what type of services you've received - if unsure then ask or correct the mistakes to come to a solution so that all parties involved settle it instead of dragging it on and on.....
I'm an insurance geek...an agent working in a broker's office. I deal with these things every day and yes, it's frustrating. Some insurance carriers are worse than others, but they ALL make mistakes. One "fun" thing: when Medicare decides they paid something they should not have. You don't want letters from their collection agency; they do not give up. Took me a year to clear one account. Not too long ago I had to request a customer's 2- year collection of Explanation of Benefits (EOBs) from an insurance company so that I could identify a missing payment. Then I had to convince the company that the provider had not been paid. We got the claim settled...and my poor client out of "collections". Bottom line: if you are getting the run around, call your employer's broker or the agent that sold you the policy and ask for help. If they don't service what they sell, they aren't worth the paper their license is printed on.
Sometimes people are still sick once they get out of the hospital, too sick to handle all of these. Nice try.
Error? haha somehow these errors always favor the corporte conglomerate. What we need is SINGLE PAYER! Remove insurance from the equation all together.
"When people make "honest" mistakes, the chances are exactly 50/50 of that error being in your favor. This is not what studies have found --- in real life the errors are over 90% in favor of the biller."
Please cite the study that makes this claim. When you do so, please ensure that this study is related to the topic of the article (billing error) and not fraud.
Also, please qualify the snippet "in favor of the biller." Do you feel like billing individuals and dealing with the overhead of following that payment up repeatedly as well as dealing with people who don't have the ability to pay compensates in such a way as to actually be in favor for the provider when they could make a painless 3rd party payer collection?
This article is but one, out of the growing many that continue to define ways to "float" others' money (without their knowledge or consent) for corporate profit, and pay nothing for the "borrowing" of the capital in the interim.
If you think that this sort of usury only pertains to Insurance, think again: What is the annual institutional withholding of "thirteenthly pay" for a public employee who works 12 months a year, on a monthly salary?
In the case of public sector workers, in many instances (e.g., Educational), the institution's monies are governed and adjudicated by the Banks that have been contracted to oversee their finances.
It is high time to blow the whistle on this unconscionable exercise of corporate-sponsored "floating fraud".