- December 2, 2023
- Posted by: legaleseblogger
- Category: Related News
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Addressing Billing Issues in Medical Procedures
My partner and I recently encountered a frustrating situation related to billing for a surgical procedure. Despite our efforts, we have been unable to resolve the issue with the hospital and doctor’s office. This has left us feeling overwhelmed and unsure about what to do next.
The trouble began when my partner was scheduled for surgery in the summer. We were asked to pay around $400 in advance while waiting at the hospital for his admittance. However, a few hours later, we were informed that the surgery had been canceled due to equipment problems, and it was rescheduled for a later date.
Upon returning for the rescheduled surgery, we were surprised to learn that the cost had increased to $1200. We were confused, as it seemed unreasonable for the same surgery to have tripled in cost within a short span of six weeks. Despite their insistence, we declined to pay the additional amount, as it seemed unjustified.
Upon further inquiry, we discovered that the doctor’s office had coded the procedure differently, leading to the discrepancy in the billing. However, when we approached the doctor’s office for assistance, we were informed that they were experiencing difficulties due to a change in their parent organization. This change was preventing them from resubmitting the billing information.
The hospital, on the other hand, was uncooperative, stating that the issue lay with the doctor’s office and that they were unable to intervene. Despite making repeated attempts to resolve the issue, my partner has been met with unhelpful responses and has been urged to simply pay the additional $800 in order to avoid negative repercussions on his credit.
Feeling frustrated by the lack of accountability and transparency, we are unsure about our next steps. It is unfair for us to be burdened with an extra $800 for a mistake that was not of our making. It is far more than a sum to be dismissed as inconsequential, and we are at a loss about how to proceed.
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Do you actually know that that $400 was the full payment and not just an initial payment? Usually (in my experience) they donÔÇÖt know the end cost until after itÔÇÖs done and after insurance has done their thing.
The doctors office said they had ÔÇ£trouble resubmittingÔÇØ. Ok. What did they say the next step was?
There isnÔÇÖt enough information here.
You said it was ÔÇ£coded differentlyÔÇØ but what was actually done and what were the codes used?
Coded differently the second time doesnÔÇÖt necessarily mean it was coded incorrectly. The first estimate may have been the incorrect one.
Something could have changed about the procedure. Screening to diagnostic, for example.
You canÔÇÖt resolve the issue without more specifics.
File an appeal with the insurance company. Call their insurance company and advise them of the issue and ask to do a verbal appeal regarding the situation, get the address to send a written appeal and send it to them as well.
They should handle the situation. Do not pay anything else to the provider and advise them you’ve filed an appeal regarding the bill.
It is unclear to me who you owe $400 to. I do not know why the hospital is referring you to the Doctors office re: their billing, unless it’s the doctor you owe the money to.
A general idea of bills/charges you should have is: the hospital will charge for use of their surgical suite, or ‘room.’ this is billed as a charge under the surgical CPT code. Your surgeon will also have a charge for their services under the same CPT code. These codes should match, but that is only if the surgeon independently charges for their services. Some providers are employed by the hospital and so the full bill would come via the hospital. The hospital may also have fees for meds, materials, etc. These are usually ‘rolled into’ the CPT code, so an ITEMIZED bill would show you all these small fees. If anesthesia administered by a Anesthesiologist or their Assistant is used, there will be a bill for this. The anesthesia is often a ‘suprise’ bill as patients aren’t usually notified if the Anesthesiologist is independent, in network, and a separate service. So review any paperwork re: the procedure that discussed anesthesia and your responsibility, if it was administered by an Anesthesiologist/Assistant. Depending on if labs/pathology are operated by the hospital or your samples are sent to an independent lab/pathologist, those too may be separate bills.
My recommendation is this: request from the hospital both the records for each surgical date of service AND the itemized bill for each date of service. Then, do the same from the Doctors office. Then, call your insurance provider and ask them if they have claims for these dates of service. I would expect if the insurance company received a claim you would have been sent an Explanation of Benefits (EOB). If you have the EOBs, check those against the hospitals and the Drs records/claims/bills. Sometimes it is enough to just request these records to get them to adjust the amount owed or have them fix an error. If after receiving the information you find there are errors in the records vs. what you were billed, you can ask your insurance company about the next steps.
Hope this helps.
Is the $1200 a copay with insurance or are you self insured?
Has a similar issue a few years ago. Went in for surgery the doctor charged me $1200 upon walking into the building. When I got done my insurance said they wouldnt cover most of it. Hospital charged me $2200 which is what I was told it would cost total. I let them know I already paid $1200 and they didnt believe me even with a receipt I told them to talk to the other office and figure it out but they said the office I went to is no longer a part of their company so its not up to them.
Anyways I paid the full amount to avoid going to collections and then wrote a few emails to the billing departments of both offices and did the most annoying thing you can do and CCÔÇÖd everyone I could find on the administrative side of the hospital I could find online that I thought would be above the billing department. DidnÔÇÖt even get the curtesy of a response but I did get a refund check in the mail a month later.
What does the EOB say is patient responsibility?
It sounds like you don’t owe them anything since they were a different organization back when he saw them before.
Contact your State Department of Insurance. They should have a ÔÇ£watchdogÔÇØ committee for fraud. Most likely a little nudge from them will put the fire to their feetsyÔÇÖs and they will get it straightened out!
You or your partner must pester/haunt the doctors office until a resolution is found. DonÔÇÖt be a hostage to the credit history.
Look up No Surprises Act and Good Faith Estimate. Hospitals are required to provide you with an accurate estimate of your total charges before they see you. You can not only get the balance back down, but get a lawyer and go after them for harassment.
Ask the doctors office to call the hospital with you on the phone.
Call their billing department. Bring it up. When they say they won’t remove the charge ask then who to contact to get a copy of your full medical record, as this is an error in your chart and you want to know if there was anything else erroneously written in your chart, falsifying your personal health information.
They’ll work with you very quick.
Does your insurance company have an advocate department or do you have something like FreshBenies through your company? They have a liaison that handles bill issues for you.
Call your insurance company to advocate for you. They donÔÇÖt what to pay more than they need to either.
Make a meeting with the billing office and get your insurance on speaker phone. Go through dates and billing codes. Because the orders for the surgery were submitted BEFORE the change there may be a global billing aspect. Meaning, they have to pretend they still are structured like they were. But this is stuff for them to duke it out with the billing office.
DonÔÇÖt worry about credit. Medical bills are non-reporting. And they can take MONTHS to bill you, so all the codes may not even be entered into their billing system.
I’ll just mention that if you get your balance under $500 it won’t effect your credit. You still legally owe the money but at least there’s that.
I had to deal with a provider that failed to pre auth something that I specifically asked them to, that portion of the 70k procedure was rejected by my insurance.
Something that I found, that IÔÇÖd recommend for anyone, is to start recording your calls. Always notify them the call will be recorded. If I had done this when I asked them to pre auth it and they said they didnÔÇÖt need to then I would not have argued for six months. That being said, once I did start recording I found they became a lot more careful to give me an accurate answer. They will hesitate to say ÔÇ£nothing I can doÔÇØ if there actually is something they can do and they lied to avoid dealing with it because they donÔÇÖt want the recording to come up during a lawsuit and it turns out they got caught in a lie.
In my case, my company has a perk with a third party contractor to handle medical billing. The contractor caught with them for 6 months on my behalf including them ÔÇ£losingÔÇØ my paperwork multiple times and ÔÇ£forgettingÔÇØ about my case repeatedly. They ended up having to pay me the money back when they lost at tribunal.
It doesn’t matter if the original price changed as long as they informed you before the procedure. That doesn’t mean is is correct though. Ask for the itemized bill that shows the codes and for the surgical notes. Compare these to the original code and the code the doctor submitted. For example if the doctor submitted a code for 5mm lateral incision and the new code is 5mm deep tissue incision and the surgical notes say 5mm lateral incision you have a case. If the surgical notes match the code they billed, then it is correct. If the surgical notes don’t match the code, file a dispute and and say you believe it may have been codded in error and request that they review the surgical notes and point out where you think the error is. The hospital will blame the doctor and say that’s the code the submitted but they can read the surgical notes wrong and apply the wrong code. Hospital’s make billing mistakes all the time.
Go back to your doctor and get the correct CPT code for for the surgery. Ask your doctor who ordered the procedure which is the correct price.
The amount they ask for upfront from an insured patient is rarely the full amount.
You should get a a statement of benefits showing the total cost and how much the insurance paid and how much you owe.
You’ve received solid advice from others here, but one additional step you could consider could be to contact your health insurance company. They have a vested interest in these charges being accurate and might be of assistance. It’s their job to deal with hospitals and doctors who are dragging their feet. Remember to document each interaction and details you shared here, it will help you to have a record of who you spoke with, when, and about what.
Call the office every 10 minutes, opening to close. And yes, I’m serious. They’ll find a way to take care of it, because you’ll be screwing up their office operations.