Patient Bill Accuracy… Yep, It’s a Problem

We all go to the doctor at some point, which means that we will also get a bill of some sort, from someone. The big question is if that bill is correct or not. I find that, depending on the organization and the processes they are following, you have a 70% chance of it being incorrect. My experience tells me that often, the patient population is paying on erroneous bills, but how would you know that on your own?

I’m going to share a story that happened in my household a few months back. In December 2018, my husband had a 360-rotator cuff tear in his shoulder and needed surgery to repair it. All went well, and now he is on the road to recovery. However, one day in February, I walked in the house and heard him on the phone with someone from our insurance company. He had gone to the mail, saw his name on the Explanation of Benefits (EOB), and read that we owed $450 for something. He didn’t know what it was for, so he called. My ears perked up right away, because while he didn’t understand the Greek he was speaking, I sure did, and as I rounded the corner, I looked down at the EOB he was referencing and said, “Put me on speaker.”

I introduced myself to the agent and proceeded to tell him what was wrong with the claim. My husband’s surgery was on December 14th, 2018, and the enormous brace placed on him in the operating room (OR) wasn’t billed to our insurance company until January 19th, 2019. Why is this a big deal, you ask? Well, my deductible and max out-of-pocket were met for 2018, which meant this surgery, and everything that happened on that day, was 100% covered by our insurance. On the other hand, in 2019, all deductibles and out-of-pockets reset, meaning we would have had to cover the $450 expense.

The agent proceeded to get confirmation from the hubby to discuss the issue, and I simply said, this bill is incorrect because my husband didn’t have surgery on the 19th of January, 2019, but on the 14th of December, 2018, and the Date of Service (DOS) was billed incorrectly. The agent told us that we needed to contact the vendor and discuss with them, and I politely said, “I would like for us to do a three-way call with the vendor.”

You as the patient have the right to ask your insurance company to advocate on your behalf, and you should involve them, because providers and hospitals are more frightened of them than of you, the patient. The one caveat to this is that most of the time, these representatives are clueless too.

It took a minute, but we located the phone number of the vendor, and with the agent on the line called the company who’d billed for the shoulder brace. I took over the conversation, because the agent from the insurance company really didn’t understand the situation either. I proceeded to inform the billing personnel from the vendor that they’d billed the brace with an incorrect date of service. She then told me that it was billed with the January date because that was when the surgeon signed the order. I explained to the agent that just because the surgeon was behind on his paperwork and didn’t sign it for a month didn’t mean that they could change when the brace was delivered, which was the true DOS, December 14th. She proceeded to tell me that submitting the date the doctor signs is their company policy, and I in turn told her that they may want to change that, because they were committing fraud.

After a few more comments, she did identify that his surgery was a different date and resubmitted a corrected claim with the correct DOS. It was reprocessed by our insurance company, and lo and behold, they paid at 100%, with no patient portion for us. How many of you would have paid that bill without thinking? At least 50% of you! The moral of this story is to scrutinize everything—mistakes happen often!

With every blog I write, I will include definitions so that you can have a deeper understanding of the healthcare industry, and I will recap some high-level tips for helping you to analyze your healthcare bills. My goal, as always, is to empower you to be the best healthcare consumer possible. I look forward to your comments below, and don’t forget to submit your questions for our weekly Friday blog where we will select five of them and answer them!

Tips:

  1. Keep track of your visits and exactly what you procedures you had done. You’d be surprised at how often other items end up on your bill that you didn’t actually have done.
  2. When you get your explanation of benefits, don’t just throw it in a pile, trash it, or throw it in the shredder—REVIEW it!
  3. If you are unsure or can’t remember what you had done, ask for a copy of your visit notes/reports so that you can review for yourself what they are saying you had done and cross reference with steps 1 and 2.
  4. Remember that the folks at the insurance companies and most billing offices don’t know as much as you think, so do some research on your own first.
  5. Use customer service at your insurance company to help you investigate and clear up issues—it’s their job.

Definitions:

Explanation of Benefits (EOB): The document that patients and providers of medical services receive from insurance companies after a bill for services is submitted for reimbursement. It outlines who provided the service, who received the service, the date the service was rendered, what was done, how much the charge for the service was, how much the insurance company is allowing for the service, how much they will pay, and how much the patient will pay.

Operating Room (OR): The space where surgical procedures are/were administered.

Deductibles: An amount that insurance policies may or may not include that must be met prior to an insurance company paying out any portion of a claim submitted by a healthcare entity on your behalf.

Out-of-Pocket (OOP or Stop Loss): As part of most insurance policies, there is a yearly cap for patients to come out of pocket. On most plans, it’s after the patient has already paid thousands of dollars in healthcare costs.

Date of Service (DOS): This is the specific date that you went and received services

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