medical billing: crime or just mistakes?

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denismurf
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medical billing: crime or just mistakes?

Post by denismurf »

I have a lot of medical issues, so lots of correspondence and bills from service providers and my Blue Cross insurance co.

Couple of weeks ago I got a bill for $275 from an imaging company that apparently read an MRI or something requested by a doctor treating me.

I usually just pay these things, but this amount looked weird, so I phoned the imaging co. They told me they billed the ins co,. but the claim was denied. So I phoned Blue Cross, who told me they had no record of receiving this claim. The Blue Cross rep said she would contact the imaging co and clear this up.

Today's mail brought me an Explanation of Benefits from Blue Cross saying that they had now paid $75 on this claim, but because of a bunch of verbiage I can't understand, the amount I owe the provider (the imaging co.) is zero.

To whom can I file a complaint, or even a criminal charge, against the imaging co for billing me for an amount I don't owe and then lying about having sent the claim to Blue Cross?

Or is this just one of those things that happens and that I'm responsible for noticing?
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Re: medical billing: crime or just mistakes?

Post by Mudpuppy »

There is a popular saying in IT, Hanlon's Razor, that says "Never attribute to malice that which is adequately explained by stupidity." It's a blunt, but effective, reminder that people make large mistakes, but often do so without meaning to cause harm.

Very likely, the imaging company made a mistake in filing the claim with the insurance and did not realize it until you contacted them. There are all sorts of ways these mistakes can be made. That's why insurance companies say you shouldn't pay a bill until you get their EoB saying how much you actually owe.
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celia
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Re: medical billing: crime or just mistakes?

Post by celia »

Hi Denismurf, It sounds like you might be "new" to paying your own medical expenses. We can give you some general guidance on this.

First, Since you have medical insurance, don't pay any bills from any medical provider until they've billed your insurance AND you've received the Explanation of Benefits from the insurance company. In this case, it sounds like the medical provider sent the bill to the wrong place or had a typo in your member ID number (based on the fact you did not get an explanation of Benefits statement from Blue Cross). This can be minimized by allowing each doctor office or medical provider to photocopy your insurance card on the first visit.

In general, medical providers send in a bill for a "high amount". I know they expect to get paid less by insurance companies but they usually bill the high amount, since there are some insurance companies who will pay that much. So they end up billing everyone for that high amount, but do indeed accept less from insurance companies as payment in full. In fact, when they sign a contract with Blue Cross and other insurance companies, the cost for each service is spelled out and both parties agree to it. But if you don't have insurance, the provider is allowed to bill the patient the whole amount.

It is also quite common that the patient may have a deductible, such as $200 each year. That means the patient pays first before the insurance pays anything. But the insurance still needs to be billed so they will know the deductible has been satisfied by the patient. Co-pays by the patient are also very common, say 10% of 20% of the contracted price, after the deductible is met. Wait until you get the Explanation of Benefits before paying your share as it will tell you exactly what part of your deductible is left and what your share of the co-pay is. If you pay before receiving the EofB, you will likely overpay your share.

Call Blue Cross for any billing questions that come up. I've always found them to be knowledgeable and helpful. They understand that the person on the other end of the phone line may not be feeling great, so they can be extra helpful. (One time I had an eye infection and my regular eye doctor couldn't see me and I couldn't see a computer screen, so they found several doctors near me and gave me their phone numbers and addresses so I could at least make an appointment.)

The most important thing for you to know is that you should always see providers that are contracted with Blue Cross so you will get the most costs covered. If you go to a non-contracted doctor and it is not an emergency, they may not pay anything or only part of what they would pay for a contracted doctor.
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Re: medical billing: crime or just mistakes?

Post by leonard »

Contact a lawyer - they can assess the legalities.

Or - attempt to file a police report. If it's illegal, the cops should listen and file a report.
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Re: medical billing: crime or just mistakes?

Post by Geologist »

It's not a crime and it isn't even a civil liability. The imaging company just made an error. The upshot is that the error was fixed. Your insurance paid something and you owe nothing. All you have is some annoyance. For better or worse, this is the way medical insurance works.

As others have said, you want to see the insurance company's EOB before paying a provider. Under my medical insurance, I don't owe providers anything no matter what they say beyond what Blue Cross says I owe. This may be the same for you, but you need to know your policy. The insurance company can reject a claim, by the way, because of a mistake in the claim, but it is then up to the provider to get it corrected.
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Re: medical billing: crime or just mistakes?

Post by stan1 »

There was an error. Blue Cross resolved it for you. You owe nothing but had to spend a little time on the phone with the imaging company and Blue Cross. Case closed. Yes you are responsible for monitoring your medical bills as you would other bills or credit card charges.

Just be glad you didn't get a medical bill for services you didn't receive (bill under your name but you didn't get treatment at that facility). That's when the real headaches begin with medical billing errors.
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Re: medical billing: crime or just mistakes?

Post by nisiprius »

In my life experience, medical billing is just plain bizarre and the error rate is ten, no maybe fifty times as high as any other business. I imagine it is impossible to do it right because it is a business that consists almost 100% of custom services, no two alike, and if you pay attention you'll see how it even to keep count of number of little packages that get torn open or the number of people who came into your room to do something to you. So it's an impossible task in the first place, and they don't even pretend to try to get it right in the second place.

As a patient, unless I personally get asked to pay out-of-pocket, I don't think there's anything useful I can do. I let the medical billing offices duke it out with insurers and Medicaid. The point is not that I am unaware that I eventually pay for this one way or another through premiums or taxes or both, but that there's nothing I can do about it. I'll spend ten minutes on the phone to report any really crazy stuff (like the time they put a splint on me in the ER and the bill came back showing they'd put on two splints) and then get on with life.

And yes, the number of innocent clerical errors is so high that I would not suspect fraud without good evidence. I can see the error rate in something trivially simple. I take a grand total of six medications, including a vitamin D pill and an 81 mg baby aspirin. The "patient centered medical home" I go to maintains a medication list. Every time I go in, they give me the drug list and ask me to make corrections. They have been seeing me for five years and I'm probably in their twice a year, and they never get it right. Every time I've made a correction. And next time it comes back with a mistake. Not necessarily anything important--things like saying I'm taking a prescription timed-release aspirin when I'm really taking generic drugstore aspirin--but wrong. Harmless typos in drug names, for example.
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adamthesmythe
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Re: medical billing: crime or just mistakes?

Post by adamthesmythe »

> To whom can I file a complaint, or even a criminal charge, against the imaging co for billing me for an amount I don't owe and then lying about having sent the claim to Blue Cross?

This sort of thing happens all the time. It would become fraudulent if the imaging company was made aware of an error and refused to correct it. It has been corrected, and promptly.

You have experienced an excellent outcome. I have had a billing error that took about a year to correct. In the end it was overcorrected; they came back that they wanted to settle for less than I though I owed. At that point I stopped arguing about it.
sambb
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Re: medical billing: crime or just mistakes?

Post by sambb »

nisiprius wrote:In my life experience, medical billing is just plain bizarre and the error rate is ten, no maybe fifty times as high as any other business. I imagine it is impossible to do it right because it is a business that consists almost 100% of custom services, no two alike, and if you pay attention you'll see how it even to keep count of number of little packages that get torn open or the number of people who came into your room to do something to you. So it's an impossible task in the first place, and they don't even pretend to try to get it right in the second place.

As a patient, unless I personally get asked to pay out-of-pocket, I don't think there's anything useful I can do. I let the medical billing offices duke it out with insurers and Medicaid. The point is not that I am unaware that I eventually pay for this one way or another through premiums or taxes or both, but that there's nothing I can do about it. I'll spend ten minutes on the phone to report any really crazy stuff (like the time they put a splint on me in the ER and the bill came back showing they'd put on two splints) and then get on with life.

And yes, the number of innocent clerical errors is so high that I would not suspect fraud without good evidence. I can see the error rate in something trivially simple. I take a grand total of six medications, including a vitamin D pill and an 81 mg baby aspirin. The "patient centered medical home" I go to maintains a medication list. Every time I go in, they give me the drug list and ask me to make corrections. They have been seeing me for five years and I'm probably in their twice a year, and they never get it right. Every time I've made a correction. And next time it comes back with a mistake. Not necessarily anything important--things like saying I'm taking a prescription timed-release aspirin when I'm really taking generic drugstore aspirin--but wrong. Harmless typos in drug names, for example.

My experience is quite the opposite. All the providers use the same record system, and they have my meds and things correct. Never had a problem unless I did not update what they gave me. I also get to see all my results online anytime i want. I am thankful for the care I receive. I have never had a billing error in years.

Perhaps this is dependent on the health system in which one receives care.
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dodecahedron
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Re: medical billing: crime or just mistakes?

Post by dodecahedron »

Our family has had similar experiences to those described by the OP in the past. In some cases, the provider kept sending the bill to the WRONG Blue Cross/Blue Shield affiliate. (That is, we had a family policy from "Empire BC/BS" based in NY with out-of-state coverage for a child attending college in another state. The providers kept sending the bill to the BC/BS affiliate in that state, which kept saying they had no record of coverage for anyone with that name and policy number. The providers apparently couldn't wrap their heads around the fact that BC/BS is not a single monolith and they needed to send it to our BC/BS at the address we gave them, not their local BC/BS affiliate with a similar name and totally different billing address.)
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dodecahedron
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Re: medical billing: crime or just mistakes?

Post by dodecahedron »

sambb wrote:
My experience is quite the opposite. All the providers use the same record system, and they have my meds and things correct. Never had a problem unless I did not update what they gave me. I also get to see all my results online anytime i want. I am thankful for the care I receive. I have never had a billing error in years.

Perhaps this is dependent on the health system in which one receives care.
I am also very happy with my current provider (CDPHP, a nationally top ranked HMO). I can see all my EOB's in my on-line portal (even before they arrive via snail mail) and when an out-of-area provider (who had signed an agreement with my HMO for emergency coverage) wrongly attempted to "balance bill" me, I just called my HMO and the customer service rep intervened immediately and in real time. (Basically, he put me on hold briefly, while he called the provider and straightened the issue out, and then came back on the line to say the matter was taken care off, with my "patient responsibility" at zero, where it should be, given that I had already hit my out-of-pocket max for the year.)
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Re: medical billing: crime or just mistakes?

Post by Johno »

denismurf wrote:I have a lot of medical issues, so lots of correspondence and bills from service providers and my Blue Cross insurance co.


Or is this just one of those things that happens and that I'm responsible for noticing?
As mentioned, yes it's just one of those things that happen, and what you're responsible for (to yourself) is to compare the provider bill to the insurance company EOB, only ever pay after making that comparison, and follow up first with ins company if there's a discrepancy.

Not trying to psycho-analyze but I can say for myself I used to be super touchy about complicated and mysterious process of medical billing even when I had employer medical insurance and especially after I started having private insurance where the ending wasn't as happy in how much I had to pay out of pocket (coverage comparable to typical employer plans has long been prohibitively expensive in my state). But I learned to relax. A member of my family has had extensive treatment, with cumulatively significant out of pocket expense when all is said and done, but the provider/ins hangups haven't really been that significant.

Talking about criminal liability in a case like this is way over the top, frankly.
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Re: medical billing: crime or just mistakes?

Post by celia »

OP, I should amend my previous comment where I spoke about co-pays. If they are calculated as a PERCENT, then you have to wait for the EoB to find out the PERCENT of <what number>, which is the agreed-on price between the provider and insurance company. This amount is also called "reasonable and necessary" costs, in the medical world.

If your co-pay is a FIXED DOLLAR AMOUNT, such as $20 per office visit or $50 per ER visit, then go ahead and pay that when you see the provider. Often they will not see you without that co-pay and it avoids unnecessary billing for what you, the provider, and the insurance company have already agreed on (when you signed up for insurance).
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Re: medical billing: crime or just mistakes?

Post by goodlifer »

I have worked in a hospital business office for 10 years. This was a simple clerical mistake. What happens is that the facility you go to is supposed to forward your insurance information to any other billing entity involved, such as the radiologist in this case. Since you did not get a bill from everyone else, it would appear to me that the imaging company typed your information in wrong. Blue Cross is billed electronically. They should have known instantly that they had the wrong information. They could have just called either the doctor's office or you to get the correct info, but the biller probably handed it off to another person that is responsible for calling patients or investigating insurance problems, and then it probably sat on their desk while you got a bill. It happens quite often, especially when someone is treated in the ER. Most people do not realize that you actually generate many bills for one visit. The ambulance, hospital, specialists, and doctors each do their own billing. Usually, the people you call on the phone about a problem are not the people that actually billed your insurance, and they are not the people who put the charges on, who are not the people who treated you. Somewhere, someone is bound to mess up.

There is no need for attorneys. This is usually handled within a few minutes, not including hold time. The amount on your bill prior to insurance discounts is not an inflated amount designed to saddle people without insurance with extra costs, unless you go to a private hospital. Public hospitals that receive any type of government funding must charge reasonable and customary amounts for your specific area. The actual amount your insurance pays is determined by the diagnosis/procedure codes, not by the dollar amount. Your bill can be 1 million dollars and if the contract states they pay $75 for that specific set of codes, then that is what they pay. They may also have to pay more than the billed amount, though it is very rare. There has only been one time in my 10 years that I saw Medicare pay more than the billed amount due to the contract, that was only because the patient called to scream and say she was pressing charges because I was committing fraud. You can probably imagine how well that went down. Your copay is a flat fee that is taken right off the top of the bill. So is any deductible, if you have one. Your out of pocket expense is a percentage of the bill after insurance discounts, until you reach your max. Just as an FYI, every insurance plan (the actual plan, not just the company) has a different contract with hospitals and doctors. It is possible that you could have the same procedure done multiple times, and pay a different amount if you change from a PPO to a POS, or even if you change employers and they both have the same insurance company. I hope I cleared up some confusion for you.
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Re: medical billing: crime or just mistakes?

Post by theunknowntech »

denismurf wrote:I have a lot of medical issues, so lots of correspondence and bills from service providers and my Blue Cross insurance co.

Couple of weeks ago I got a bill for $275 from an imaging company that apparently read an MRI or something requested by a doctor treating me.

I usually just pay these things, but this amount looked weird, so I phoned the imaging co. They told me they billed the ins co,. but the claim was denied. So I phoned Blue Cross, who told me they had no record of receiving this claim. The Blue Cross rep said she would contact the imaging co and clear this up.

Today's mail brought me an Explanation of Benefits from Blue Cross saying that they had now paid $75 on this claim, but because of a bunch of verbiage I can't understand, the amount I owe the provider (the imaging co.) is zero.

To whom can I file a complaint, or even a criminal charge, against the imaging co for billing me for an amount I don't owe and then lying about having sent the claim to Blue Cross?

Or is this just one of those things that happens and that I'm responsible for noticing?
A visit to the hospital for a bump on the head, in and out, maybe a scan, and you later get informed that you were in the hospital for eight days, none of which you remember, and nobody else does either. Certainly they would have fed you, and everybody remembers THAT. (Kidding.)

There seems to be such widespread fraud in hospital billings, it's just a given. How very sad. It is so important to call (or delegate the responsibility of the call to somebody who cares about you) whatever authority is handling your medical expenses, so you don't get abused like this. Play your cards wrong, and you could very easily get wiped out. Even with the ACA, it still happens. Medical administrators are still working on ever more creative new ways to wreck you.
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Re: medical billing: crime or just mistakes?

Post by dm200 »

denismurf wrote:I have a lot of medical issues, so lots of correspondence and bills from service providers and my Blue Cross insurance co.
Couple of weeks ago I got a bill for $275 from an imaging company that apparently read an MRI or something requested by a doctor treating me.
I usually just pay these things, but this amount looked weird, so I phoned the imaging co. They told me they billed the ins co,. but the claim was denied. So I phoned Blue Cross, who told me they had no record of receiving this claim. The Blue Cross rep said she would contact the imaging co and clear this up.
Today's mail brought me an Explanation of Benefits from Blue Cross saying that they had now paid $75 on this claim, but because of a bunch of verbiage I can't understand, the amount I owe the provider (the imaging co.) is zero.
To whom can I file a complaint, or even a criminal charge, against the imaging co for billing me for an amount I don't owe and then lying about having sent the claim to Blue Cross?
Or is this just one of those things that happens and that I'm responsible for noticing?
This kind of thing happens all the time and, it seems to me, is just a billing error. As soon as you questioned Blue Cross, the issue was 100% fully resolved. You were not harmed at all - just slightly inconvenienced.

Always read and understand all bills, as well as questioning anything that you do not understand and agree with.

Almost certainly you owe zero is because the insurance company (Blue Cross) has an agreement with the provider that the fee amo9unt is only $75.

Consider yourself fortunate that you cleared this up with only ONE call to Blue Cross!
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Re: medical billing: crime or just mistakes?

Post by likegarden »

You have to have insurance for a few years to understand these clerical mistakes. You need to read your statements to verify that everything is fine. We are now with CDPHP, before with Blue Cross and things go smooth. Though before entering a clinic for a colonoscopy 2 years ago we were asked to sign that we accept individual bills from providers present at this service, so we wrote in that form that we belong to an HMO and all bills go to the insurance company first. You need to watch out or mess might start.
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Re: medical billing: crime or just mistakes?

Post by island »

Could have been the imaging company or Blue Cross who mishandled the paperwork. I don't think you can trust it wasn't lost in space at BC just because someone at BC said the claim was never sent to them. There are a lot of hands on stuff like this. Be diligent, don't expect perfection and don't always assume the worst, such as criminal activity.
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Re: medical billing: crime or just mistakes?

Post by HIinvestor »

I have had a lot of different insurance snaffus over the years but we have always managed to resolve them and I've always assumed that it was simple error. I seriously doubt any GOOD attorney would take this case unless there is a documented pattern or practice of this provider making these types of "mistakes" frequently and you could PROVE damages to yourself and others. As it is, other than a bit of extra time you spent calling your insurer, I can't see any harm or damage to you.
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Re: medical billing: crime or just mistakes?

Post by Kosmo »

Someone made a mistake at some point in the process. It was resolved with 1 phone call. No crime has been committed. Stop being ridiculous.
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Re: medical billing: crime or just mistakes?

Post by sambb »

Remember, it is always in the best financial interest of the insurance company to "have never received the claim".
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Re: medical billing: crime or just mistakes?

Post by Naismith »

Agree with much of what was said, but wanted to add that we should expect those errors to proliferate in the next few months as we go through a season of transition from ICD 9 to 10. The ICD (International Classification of Diseases) is a system that health care providers currently use to code all diagnoses, symptoms, and procedures so it has a huge impact on medical billing. By early October, everyone who gets any federal payment needs to be in the ICD-10 world. Some folks have been moving over in the last two years (as the deadline was delayed).

Also, an elder relative had major problems with her insurance billing because when an office asked her Medicare number she would rattle off her social security number. Since she gets spousal benefits, the Medicare number is actually her husband's social security number.

We also had a younger relative have a medical bill go into collections. She kept trying to pay it in person at the doctor's office, but the billing was handled by a firm in another state, and the office didn't have the up-to-date information.
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Re: medical billing: crime or just mistakes?

Post by Silverado »

Boy a lot of people are willing to accept mistakes here. Just because we have little chance of changing it doesn't make it right. Also doesn't make it right to tell someone they are ridiculous.

I walk up to you on the street and say "give me $250". Thats how the OP seems to have felt. I get it.
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Re: medical billing: crime or just mistakes?

Post by ks289 »

Silverado wrote:Boy a lot of people are willing to accept mistakes here. Just because we have little chance of changing it doesn't make it right. Also doesn't make it right to tell someone they are ridiculous.

I walk up to you on the street and say "give me $250". Thats how the OP seems to have felt. I get it.
It is understandable to be frustrated by billing mistakes. I would not advocate ignoring mistakes or claiming that it is right to allow mistakes to stand. It is another thing to speak of calling lawyers or the police or comparing it to a mugging. People who seriously believe that this is good reasoning may risk being called ridiculous.
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Re: medical billing: crime or just mistakes?

Post by pshonore »

When I go to the Doc, I just hope they get the diagnosis and treatment correct. Billing errors can be common (and a real annoyance) but are a very small and insignificant part of the process. I find the My Medigap provider does not always get billed. I suppose that's a foul up on Medicare's part, but again a few phone calls usually straightens it out.
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Re: medical billing: crime or just mistakes?

Post by cherijoh »

Silverado wrote:Boy a lot of people are willing to accept mistakes here. Just because we have little chance of changing it doesn't make it right. Also doesn't make it right to tell someone they are ridiculous.

I walk up to you on the street and say "give me $250". Thats how the OP seems to have felt. I get it.
The OP was claiming fraud because he/she was billed $275 and the insurance company settled for $75. He/she clearly didn't understand how insurance works - despite claiming to have multiple health issues. So in my opinion, it WAS way over the top to suggest that a criminal charge was appropriate.

Since you think that accepting billing errors isn't the correct approach, what do you suggest be done? The bottom line is that the situation was resolved with one phone call to the insurance company. On a scale of 0 to 10, this barely makes a 1 IMO.
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Re: medical billing: crime or just mistakes?

Post by Mudpuppy »

Silverado wrote:Boy a lot of people are willing to accept mistakes here. Just because we have little chance of changing it doesn't make it right. Also doesn't make it right to tell someone they are ridiculous.

I walk up to you on the street and say "give me $250". Thats how the OP seems to have felt. I get it.
Realistically, the exchange was more like a buddy coming up and saying "hey, you still owe me $80 for that dinner last month" and you saying "no, Bob was supposed to pay you for that". Then the buddy realizes he forgot to ask Bob for the money, goes and asks Bob for the money, gets the money from Bob, and the matter is settled. It's annoying that the buddy pestered you instead of Bob, but not fraud.

The medical billing analogy to a mugging on the street, and what would be fraud (or at least violation of insurance contracts), is if the imaging company, after receiving the $75 from the insurance, still came after the OP for the $200 difference between the original bill and what the insurance paid. That isn't what happened here.
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Re: medical billing: crime or just mistakes?

Post by czeckers »

It saddens me to hear that when an error occurs, people automatically assume fraud.
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Re: medical billing: crime or just mistakes?

Post by toofache32 »

Amazing how everyone thinks the insurance company is on their side and can do no wrong. They routinely and systematically ignore claims. Even with electronic claims filing they still say they never got it. I have seen BCBS and UHC send me an approval pre-authorization in writing, only to later deny they ever received a request for pre-authorization from me in the first place! Remember insurance companies are not in the business of paying claims....they are in the business of NOT paying claims. Yes, medical practices can make mistakes also but it's amazing how the perception by default is that the insurance company is never at fault. While the old practice was to just file it again, more and more practices are putting the burden on the patient, and rightfully so since it's the patient's insurance, not the practice's. My office does this because putting the financial burden on the patient ensures they have skin in the game and an incentive to sit on the phone with the insurance company to learn how maddening it is to deal with them. This is why I (and many docs) are dropping insurance companies and going cash only. So much simpler and cheaper. If you want to file a complaint, did you ever consider filing it with your state insurance commissioner against the insurance company? I file one of these complaints 3-4x per year. Some are fruitful and some are not.
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Re: medical billing: crime or just mistakes?

Post by sambb »

toofache32 wrote:Amazing how everyone thinks the insurance company is on their side and can do no wrong. They routinely and systematically ignore claims. Even with electronic claims filing they still say they never got it. I have seen BCBS and UHC send me an approval pre-authorization in writing, only to later deny they ever received a request for pre-authorization from me in the first place! Remember insurance companies are not in the business of paying claims....they are in the business of NOT paying claims. Yes, medical practices can make mistakes also but it's amazing how the perception by default is that the insurance company is never at fault. While the old practice was to just file it again, more and more practices are putting the burden on the patient, and rightfully so since it's the patient's insurance, not the practice's. My office does this because putting the financial burden on the patient ensures they have skin in the game and an incentive to sit on the phone with the insurance company to learn how maddening it is to deal with them. This is why I (and many docs) are dropping insurance companies and going cash only. So much simpler and cheaper. If you want to file a complaint, did you ever consider filing it with your state insurance commissioner against the insurance company? I file one of these complaints 3-4x per year. Some are fruitful and some are not.

Thanks for this perspective.
Impromptu
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Re: medical billing: crime or just mistakes?

Post by Impromptu »

Are patients willing to get rid of third party billing entirely? I doubt it.
I'll gladly pay you Tuesday for a hamburger today.
toofache32
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Re: medical billing: crime or just mistakes?

Post by toofache32 »

Impromptu wrote:Are patients willing to get rid of third party billing entirely? I doubt it.
Providers file insurance as a courtesy to the patient, it is not required.
HIinvestor
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Re: medical billing: crime or just mistakes?

Post by HIinvestor »

Actually, it depends onthe contract between provider and insurer. Our insurer makes providers sign a contract that they will bill insurer first and then collect from the insured and never send insured a bill for the full cost of services and have insurer wait for reimbrusement IF the provider is "participating and preferred" and to be reimbursed at the higher rate than the non-participating, non-preferred docs (who can bill in full and have YOU, the insured do the paperwork and hope you get some reimbursement for what you pay).
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Epsilon Delta
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Re: medical billing: crime or just mistakes?

Post by Epsilon Delta »

toofache32 wrote:
Impromptu wrote:Are patients willing to get rid of third party billing entirely? I doubt it.
Providers file insurance as a courtesy to the patient, it is not required.
Courtesy is part of doing business. Billing is part of doing business. Providers are free to run a business with no third party billing, or even go cash only. The vast majority are not willing to do so. To put it another way: courtesy is not an option if you want to stay in business.

Collectively the providers have as much at stake as the patients, and individually they have more at stake. Saying it's not your problem is council of despair that's not going to fix anything.
toofache32
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Re: medical billing: crime or just mistakes?

Post by toofache32 »

Epsilon Delta wrote:
toofache32 wrote:
Impromptu wrote:Are patients willing to get rid of third party billing entirely? I doubt it.
Providers file insurance as a courtesy to the patient, it is not required.
Courtesy is part of doing business. Billing is part of doing business. Providers are free to run a business with no third party billing, or even go cash only. The vast majority are not willing to do so. To put it another way: courtesy is not an option if you want to stay in business.
Collectively the providers have as much at stake as the patients, and individually they have more at stake. Saying it's not your problem is council of despair that's not going to fix anything.
I am the only provider in my group that is in network with any medical plans. And I produce the least of my group. I am slowly dropping insurance plans one by one. With each plan I drop, I see my income go up, costs go down,and headaches decrease and the quality goes up. Just like any other business, it's not my problem how you pay, as long as you pay. If you can get reimbursed from someone else that's great. This is a great example of the 2-tiered system we are moving towards.
Mudpuppy
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Re: medical billing: crime or just mistakes?

Post by Mudpuppy »

HIinvestor wrote:Actually, it depends onthe contract between provider and insurer. Our insurer makes providers sign a contract that they will bill insurer first and then collect from the insured and never send insured a bill for the full cost of services and have insurer wait for reimbrusement IF the provider is "participating and preferred" and to be reimbursed at the higher rate than the non-participating, non-preferred docs (who can bill in full and have YOU, the insured do the paperwork and hope you get some reimbursement for what you pay).
I believe toofache32 is a dentist, and dental insurance probably has different billing contracts than medical insurance. It is not uncommon for dental insurance to allow patients to submit bills for reimbursement for example, while most medical plans (with some exceptions of course) prefer direct provider billing, and thus would have it in the contract. Plus, he has said he's dropping insurance contracts and moving to cash-only, which, whether doctor or dentist, means one no longer has to care about the contents of the contract as the contract no longer applies.
toofache32
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Re: medical billing: crime or just mistakes?

Post by toofache32 »

I am both a physician and dentist. Dental insurance is a completely different animal and my comments here are in regards to medical insurance. You are correct that more plans are requiring providers to do the billing these days. This further insulates the patients from the madness required to get them to pay.
Jonathan
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Re: medical billing: crime or just mistakes?

Post by Jonathan »

Our medical providers and insurance companies often make honest mistakes, especially with my wife's medical bills during pregnancy. Many times we've had to read through the fine print in our policies and call them out on an honest mistake. When debating these honest mistakes, we often get ping-ponged back and forth from the honest medical service provider to the honest insurer. It's gotten to the point where we don't pay any significant bill without first reviewing our coverage to see if an honest mistake was made.

So far we haven't yet noticed an honest mistake in our favor, but I'm sure that, since these are all honest mistakes, statistically, there is just as great of a likelihood of an honest mistake occurring in our favor as it is in theirs.

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Mudpuppy
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Re: medical billing: crime or just mistakes?

Post by Mudpuppy »

Jonathan wrote:So far we haven't yet noticed an honest mistake in our favor, but I'm sure that, since these are all honest mistakes, statistically, there is just as great of a likelihood of an honest mistake occurring in our favor as it is in theirs.
I've had an honest mistake in my favor. One of my specialists did not file the requested documentation within the specified time frame by the insurance company, so the insurance company denied the claim. The specialist ended up writing off the bill entirely, rather than bill me for the service. While that instance went in my favor, that's not really in the specialist's favor though.
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unclescrooge
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Re: medical billing: crime or just mistakes?

Post by unclescrooge »

My wife works at a hospital, and she cut her finger on something. She walked down to the ER to get a bandaid.

Someone there told her it's a workers comp thing so she needs to fill out some paperwork, which she did.

Couple of weeks later, she got a bill for $2,450 in the mail.

It was resolved eventually, but that's consistent with my understanding of how medical billing works!
new2bogle
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Re: medical billing: crime or just mistakes?

Post by new2bogle »

I don't pay medical bills until they are at least 60+ days over due. Case in point: I had a bill that was ~$1500. Few weeks later, the EOB comes in at something like $500. Then I get an updated bill for ~$500. A month after this, the same bill is now magically $39.95. Now it is time to pay.

It really is magic.
trueblueky
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Re: medical billing: crime or just mistakes?

Post by trueblueky »

toofache32 wrote:
Impromptu wrote:Are patients willing to get rid of third party billing entirely? I doubt it.
Providers file insurance as a courtesy to the patient, it is not required.
It's required if they want my family as patients.

As I once explained to a hospital administrator, part of what Im paying you to do is file paperwork with my insurance company.
toofache32
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Re: medical billing: crime or just mistakes?

Post by toofache32 »

trueblueky wrote:
toofache32 wrote:
Impromptu wrote:Are patients willing to get rid of third party billing entirely? I doubt it.
Providers file insurance as a courtesy to the patient, it is not required.
It's required if they want my family as patients.

As I once explained to a hospital administrator, part of what Im paying you to do is file paperwork with my insurance company.
How are you "paying the hospital" to do paperwork? Most contracts forbid billing for these services. On the contrary, they are giving huge discounts to you and your insurance company.

The interesting part is that in the insurance world, nobody is any more special than anyone else, and there is no reason to chase after any patients who are high maintenance. Insurance patients tend to greatly overestimate their value to a practice. If someone is a troublemaker or "red flag" patient, then they move on to the next person. This is why there is no customer service in the insurance world, because the provider/hospitals get paid the same regardless of how difficult a patient is to work with. There is no incentive to work harder for you when your insurance pays just as bad as all the others. Remember, the reason providers/hospital sign up for insurance is because they get to trade money for volume. With such high volume, each patient is worth less individually. This is what we sign up for when we sign up for insurance, and these are very basic business principles. This is actually very Boglehead in terms of the cost-savings and efficiency.
Last edited by toofache32 on Thu Sep 24, 2015 9:21 pm, edited 1 time in total.
katnok
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Re: medical billing: crime or just mistakes?

Post by katnok »

Here's another example of how insurance companies not want to pay...
One of the Medicaid insurances that we accept denies ALL claims for 'inpatient coverage' stating the patient's condition doesn't meet the criteria for inpatient coverage, but would cover only for observation status DESPITE meeting their written criteria. So, as an admitting doctor I need to call for what they call peer to peer review, and they finally approve inpatient status.

When we call the insurance company, we give the information that they need, which is ALREADY documented in patient's medical record, which they have access to.
So, why do you think they do this? They do this because, due to time constraints, some of us might just ignore it and accept what they pay for observation status.

Do you not want to call this fraud?

I wish patients fight against such practices by the insurance companies than blaming it on doctors. Honestly, we are fighting FOR patients on their behalf EVERYDAY. Most patients do not realize this.
trueblueky
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Re: medical billing: crime or just mistakes?

Post by trueblueky »

toofache32 wrote:
trueblueky wrote:
toofache32 wrote:
Impromptu wrote:Are patients willing to get rid of third party billing entirely? I doubt it.
Providers file insurance as a courtesy to the patient, it is not required.
It's required if they want my family as patients.

As I once explained to a hospital administrator, part of what I'm paying you to do is file paperwork with my insurance company.
How are you "paying the hospital" to do paperwork? Most contracts forbid billing for these services. On the contrary, they are giving huge discounts to you and your insurance company.

The interesting part is that in the insurance world, nobody is any more special than anyone else, and there is no reason to chase after any patients who are high maintenance. Insurance patients tend to greatly overestimate their value to a practice. If someone is a troublemaker or "red flag" patient, then they move on to the next person. This is why there is no customer service in the insurance world, because the provider/hospitals get paid the same regardless of how difficult a patient is to work with. There is no incentive to work harder for you when your insurance pays just as bad as all the others. Remember, the reason providers/hospital sign up for insurance is because they get to trade money for volume. With such high volume, each patient is worth less individually. This is what we sign up for when we sign up for insurance, and these are very basic business principles. This is actually very Boglehead in terms of the cost-savings and efficiency.
I'm paying the hospital because those costs are built into their rates and their contract with the insurance company (that my former employer and I pay) requires them to file directly.

We're fortunate to have a BCBS storefront in our town. If we have an issue between BCBS and the service provider, they're usually able to clear it up while we're in the BCBS office.

We received a hospital bill for an operation that never happened. When we showed up the equipment wasn't there, so the operation was scrubbed that day. The operation later occurred at a different hospital, same surgeon. The hospital had pre-loaded all the codes. To get them to back that out, we had to go to the hospital (phone calls didn't work) and insist they audit the procedure based on their operating room notes from an event that didn't happen. That took months to resolve. BCBS had our back, and we made sure they didn't pay that mistaken bill (not accusing anyone of fraud). Still, it makes me wonder how much of the bill for surgeries are based on what happens and how much is routinely preloaded.
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ejvyas
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Re: medical billing: crime or just mistakes?

Post by ejvyas »

I had multiple billing issues during our pregnancy with UHC and local providers. Once I fought with the lab for more than 6 months when they tested my wife and marked her as a male which UHC gladly declined saying how & why pregnancy hormones are tested on males.

More recently we have moved to BCBS and feel their billing is more consistent and I havent had any issues. Also, I use a service called Health Advocate that can do all this work for me - sorting out billing issues, billing codes, appointments, medical records. I wish I had this service during our pregnancy days. It would have saved me tons of time.

I use HDHP so I look forward to every bill, EOB and billing codes
trueblueky
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Re: medical billing: crime or just mistakes?

Post by trueblueky »

http://www.nytimes.com/2015/09/22/upsho ... .html?_r=0

A physician relates his experience as a patient.
frequentT
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Re: medical billing: crime or just mistakes?

Post by frequentT »

How does a Health Insurance Company make money?

1. Efficiently collect the premium.
2. Deny the claim or
3. Discount the claim or
4. Challenge the claim or
5. Hassle the patient/beneficiary to provide more documentation or
6. 'Temporarily' forget about the claim and
7. Try to collect from the patient years later by subtracting payment from the provider: then claim the documentation has 'been lost'
8. Then when all of the above fails, send the account to a junk yard dog collection agency.

I have had all of the above tactics used against our family in recent years. I can defeat them by:

Communicate in writing when I smell a problem brewing. Keep a long paper trail of correspondence. Dispute, in writing, every attempt that is made to foist the problem on you. Avoid using email: (did not receive the email is a common defense). Make them handle your paper! Send them cc's of the paper trail. (they may soon realize that you keep better records than them).

When necessary send a written complaint to the State Insurance Commissioner with a copy to the CEO of the Health Plan. These problems are so prevalent that the CEO must employ a team of ombudsman to fix problems and errors within their organization. They work almost exclusively for the CEO to get the problem off the CEO's desk.

This is alot of work, however, it is the reality.

Good luck!
Footure
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Re: medical billing: crime or just mistakes?

Post by Footure »

You're right to question anything that looks suspicious in the medical billing world. I used to work as an auditor for health care facilities and they make a lot of mistakes. Not just with billing, but keeping paperwork and records for the right amount of time, etc. Like someone else said, I doubt it's done intentionally, but you're ultimately the one who has to handle it.
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