When the Bill is Just Wrong

Health care bills have mistakes, sometimes lots of them.

The figure most often quoted is that up to 80% of medical bills have errors. I’ve looked for the original source of that statement without success, but I did find one medical bill review company, Medical Billing Advocates of America, who noted that in their practice 3 out of every 4 bills they review have errors. (Caveat: Theoretically only people who think they have a billing issue would be submitting their bills for review, so this may create a falsely high rate.)

Still, you probably look over your restaurant bill and ask the waiter about charges you see that don’t look right before you pay it, right? The same applies for medical bills – and even though you may not fully understand everything that was ordered for you, asking about what’s on the bill you don’t recognize before you pay it is just smart.

CPT and ICD Codes

As with most of healthcare, there’s a back-story here. In our healthcare system, providers get paid for what they do, and everything they do has a code associated with it. ICD coding, also known as International Classification of Disease codes, is a widely recognized international classification of diseases and/or diagnoses. It is developed, monitored and copyrighted by the World Health Organization.  Point of interest: These codes were updated in October 2015, and made coding considerably more detailed. Although most provider systems have been updated accordingly, it has still been a source of some errors.

CPT codes, or Current Procedural Terminology, are a US standard for coding medical procedures and to standardize medical communication. It is maintained and copyrighted by the American Medical Association. CPT codes are the basis for the retail pricing that tells insurance companies what they are to pay a provider.

You can’t have a procedure code without having a diagnosis code. So ICD and CPT codes go hand in hand. And, payers have built complicated systems that review what’s submitted to them to know that certain procedures go with certain diagnoses. Likewise, certain procedures don’t go with certain diagnoses. (EX. Blood sugar testing goes with a diabetes diagnosis, but doesn’t go with a fractured ankle).

What might a billing mistake look like?

  •      You get billed for a woman’s heart program work up. Except you’re a man.
  •      You get billed for 111 of something, instead of the 1 you got.
  •      Your bill shows you to have been in a private room in the hospital when you were in a shared room.
  •      Your skilled nursing facility bill shows daily therapy treatments when you had been readmitted to the hospital.

Generally these aren’t malicious mistakes. But they don’t usually benefit patients.

Why do they happen? As healthcare gets more automated, it’s important to remember that for the most part, the data that goes into our records is still entered by humans. A nurse entering the number of dressings applied might have a heavy keyboard touch and a 1 becomes 111. The wrong CPT code (women’s heart program work up) gets clicked instead of the correct code (the correct code for a man’s heart program workup is probably adjacent to or under the women’s heart program work up). A tech clicks on private room when you’re admitted, but no private room is available and you end up in a shared room but the record isn’t corrected. The nursing facility has automated your therapy visit schedule and didn’t discontinue them when you went back to the hospital for 2 days.

What’s an empowered patient to do with a billing mistake?

  • Don’t assume that medical bills are accurate.  While there’s a good chance your bill is “accurate enough,” it’s important that you at least scan every medical bill you receive, even if your insurance is paying the claim.  Most of us can eyeball our bills and will recognize things that just don’t look right.
  • If you don’t recognize or understand a charge, contact the provider and ask for a detailed bill so you can see the diagnosis and CPT codes for every line item in the bill. Some hospitals are voluntarily providing detailed bills with their statements. If you’re really curious, you can Google the CPT code(s) and the associated procedure will usually pop up.
  • Make sure your insurance Explanation of Benefits statement aligns with the bill you’ve received. Some insurers have programs that will flag errors (wrong services attached to a diagnosis, EX. diabetes testing for the fractured ankle), often resulting in payment being denied. While many providers will work to resolve claims denied for this reason, keep in mind that it is still ultimately your responsibility to find out what’s wrong with the bill (or to work with your provider and/or insurer to do so).
  • Especially in the hospital, consider keeping a journal of what services you receive (or ask a loved one if you’re not up to it). List what times and what medications are administered, whether by mouth, or IV. Note any tests and lab work you have. Ask for and write down the names of doctors who see you and their specialty.  List any items (e.g. bandages, medications, etc.) you are discharged with. Ask for a discharge summary before you go home. Keep these notes in case you need to refer back to them later if you see something unfamiliar on your bill or Explanation of Benefits statement.
  • Many private patient advocates, including our practice, research medical bills, and identify and resolve these errors. But if your bill is related to a long, complicated interaction, consider a first step in hiring an advocate with special expertise in medical coding.  Along with your notes from a hospital stay, these experts can determine when codes were used that allow hospitals to charge more, vs. a different code that would have a lower fee associate with it as well as codes that really aren’t associated with the diagnosis, and can be an instrumental first step in the process of negotiating high out of pocket costs for this kind of bill.  

Your health and financial well-being are just as important as that special night on the town.  Don’t be afraid to ask about what’s on your medical bills before you pay it!

 

 

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