Healthcare and Medical Billing
The Heathcare System and Medical Bills
Perhaps one of the saddest things about our healthcare system is that there is an occupation dedicated towards correcting what hospitals and insurance companies get wrong. And it isn’t the lawyers, believe it or not.
There are people out there called “medical billing advocates,” and their job is twofold: First, they make sure that all medical charges from the hospital are legitimate, and secondly, they help convince insurance companies to pay for medical claims that were denied for no good reason.
Most of them don’t charge by the hour. Just like injury attorneys, they charge as a fee a percentage of the money that they save you. While we are glad that such a position exists, we think it’s quite sad that they have to be in business at all. We are equally sad that business is apparently booming for them.
According to a group called the Medical Billing Advocates of America, there are errors on fully 80% of medical bills. And by “errors” they don’t mean mistakes in spelling in punctuation. We mean charges that are made that shouldn’t be there.
There are duplicate charges, price gouges, and “creative rebranding” of standard things in order to make them seem more expensive than they really are. For instance, one bill that was scrutinized listed a box of tissues as a “mucus suppression system.” A box of tissues at the average grocery store will run you $2.00. But a “mucus suppression system at the local hospital will run you $30.00. A second bill that was scrutinized charged some poor child $100.00 for the use of a teddy bear, which was billed as a “cough support system.” A single Tylenol, which is listed as “pain relief therapy”can cost you about $25.00.
Overnight stays also provide a billing bonanza for hospitals. Normally the room is supposed to have a flat rate, just like in the Holiday Inn. But quite often you will see surcharges for sheets, bedding, heating and/or cooling costs, extra blankets, and the electricity that it costs to run the television/adjustable bed/heart monitor.
According to the MBAA, the best thing that you can do is demand a line by line summary of your medical charges, and take the hospital to task for anything that is fishy (and the odds are that you will find something.) If your medical providers remain obstinate over the charges, getting a billing advocate would be a smart way to go about paying a fair price for your medical treatment.
Billing advocates also offer services regarding your insurance company, who are also no slouches in the “billing error” department. The main difference is that they have a tendency to miscategorize legitimate procedures as “medically unnecessary” or “voluntary.” Considering how difficult the medical billing process is between doctors and insurers, this is pretty easy to do. Consider the “classification” process.
Let’s say you go to the hospital with a sprained ankle. The doctor x-rays it, binds it up, gives you some crutches and sends you on your way. That’s about as straight forward as it could get, right? The difficulties begin when the doctors make an attempt to get their money. Doctors don’t just send in an invoice that says “Sprained ankle, x-ray, wrap, crutches, $400.00.” They have to fill out a series of labyrinthine codes, and they have to do it perfectly. And is there a code that says “sprained ankle?” No. There are DOZENS of codes for a sprained ankle. Is there a code that says “x-ray?” No. There are DOZENS of codes for an “x-ray.” And each code has to fit perfectly with your injury because if it isn’t, the insurance company denies it.
There are CPT codes, of which there are thousands, which cover what are called “Current Procedural Terminology.” There are ICD codes (International Classification of Diseases,) of which there are thousands. There are ICF codes (International Classification of Functioning, Disability and Health,) of which there are thousands. There are DRG’s (Diagnosis Related Groups,) of which there are over five hundred. There are NDC codes (National Drug Codes,) of which there are thousands. And there are DSM-IV-TR codes, which cover the entire spectrum of mental illness. And within these thousands of codes are diagnoses that seem practically identical but aren’t at all, at least when it comes to whether or not the insurance company will decide to pay for it. The sheer numbers of these codes (as well as the numbers of redundancies that exist within them) make it quite easy for insurers to choose not to pay at all.
Again, this is where the billing advocates come in. As well as being experienced in the creative billing of hospitals, they also know the coding system backwards and forwards, and they also know how insurance policies work. They are quite good at getting denied claims reversed. We can’t help but shake our heads at the idea that these professional billing advocates even have to exist at all. It speaks volumes about America’s health care system that there are classes of professionals whose job it is to simply keep you from getting ripped off. What sort of system do we have where it is considered standard operating procedure to have an 8 in 10 chance of getting overcharged at the hospital? Or a 6 in 10 chance of getting a claim denied unfairly?
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As a future Medical Biller/Coder I understand your comments on things being billed for what services were incorrectly categorized but you need to look back at the Doctor's Office. If not properly written out on the Medical Orders the Billing can and will perhaps be incorrectly billed. That needs to be rectified and the Coder needs to know what they are doing in order to bill the Insurance Company. Again this falls back on poor Education and incorrect coding from the Doctors themselves. Some Doctors Offices have forms for the Doctor to fill out and with them they have Codes on them so that will help somewhat.