Healthcare Savvy

Claim Modifiers: More Code-Speak on Your Medical Bills

April 26, 2013 in health care costs, Health Insurance, Hospital Bills, Insurance Bills

If you have ever been hospitalized or had a major test/procedure performed, you may have received a frustratingly hard to decipher medical bill from your provider. And, if you are insured, you will also have received a similarly cryptic Explanation of Benefits (EOB) describing your insurance company’s payment decision. (The EOBs can sometimes be a bit clearer and more detailed than the average provider bill.) To the average lay person, medical bill jargon does not sync with customer psychology in the way that other bills, like retail, residential services, etc. do. Most other industries present their bills in a careful way, focusing on clear billing, to make sure that customers know why they have financial responsibility.

CPT and Claim Modifier Codes

With that in mind, let’s look more closely at some of the usual suspects that show up on an unreadable medical bill. One type of common code is called a Current Procedural Terminology or CPT code. This code, in plain English, represents a service that a doctor (or other medical professional) provides.

CPTs often do not “read” well. Patients not involved in the medical industry themselves may have no idea what one of these codes represents on a bill. Looking at the charge associated with it can be frustrating when there’s no common-vocabulary explanation to make the patient remember just what was done in the provider office. This means that patients who are proactively concerned about their care, and costs, will often call providers or insurers just to ask “what does this CPT code mean?”

About Claim Modifiers

Claim modifiers are additional digits attached to a CPT to explain to an insurer or other party how a procedure may have differed from “the norm.” Some modifiers are also used to differentiate a core service from an advanced service level based on the doctor’s documentation. Read the rest of this entry →

Tags: claim modifiers, CPT codes, CPT modifiers, decipher a medical bill, medical bill care and cost, medical bill help, medical bills, understand medical bill jargon No Comments »

Here’s one reason you can’t find health care prices…

March 18, 2013 in Health Insurance, Hospital Bills, Member Stories

Most states don’t have laws requiring hospitals and other providers to tell you how much anything costs.

That’s the finding of a report that gives 29 states an “F” for transparency in health care pricing and nine a “D.” As Kaiser Health News reports, a group that includes some of the country’s largest employers plans to issue annual report cards on transparency.

Massachusetts and New Hampshire are the only two states (in blue) that get “A”s. The provision of the Massachusetts law that says insurers and providers will have to give you a price for an MRI, if you call, takes effect later this year. I’ve tried to find out how much hospitals and labs in the Bay State charge for services; it’s very difficult. So for now, the “A” awarded to Massachusetts must be for intent, not action.

Please Medicare, you can do better than this

March 5, 2013 in health care costs, Hospital Bills, Member Stories

I wrote to Medicare a while back, asking for a price. I know nothing is simple in the world of health care costs, but I just needed one number, a number Medicare uses, I assume, to calculate payments to doctors and hospitals all the time.

Here’s what I wanted to know: how much does Medicare pay a particular hospital in Boston for a colonoscopy (it was for a story I wrote about searching for the best colonoscopy in our medical Mecca).

The first response I got, at a time when we’re supposed to have more price transparency, was ridiculous. If I can figure this out, I should be awarded an honorary masters in something, don’t you think?

For the inpatient hospital side:

If you want to calculate a hospital specific DRG payment for a specific fiscal year, look at that year’s IPPS Impact file to get the hospital’s wage index.

Then you can look at Table 5 for the FY 2009 Final Rule to get the relative weights for the MS-DRGs you are interested in. Finally, you can determine the FY 2009 labor related share and non-labor related share rates from Table 1A in the FY 2009 Final Rule.

These files and tables can be found here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Acute-Inpatient-Files-for-Download-Items/CMS1247872.html

Then the hospital specific DRG payment can be calculated as follows: (wage index x labor related share + non-labor related share) x DRG relative weight.

For the outpatient side:

Medicare Part B data by procedure code for specific years are posted: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/NonIdentifiableDataFiles/PartBNationalSummaryDataFile.html Data are presented by 5-digit code so you would need to know the code for CT scan and MRI. Code range categories are identified in the readme file which is included in the zipped file.

A colonoscopy for the inpatient side does not affect the MS-DRG assignment. You will only be able to narrow it down by looking at the procedure codes. Below are the two most common reported.

ICD-9-CM procedure code 45.23, Colonoscopy

ICD-9-CM procedure code 45.25, Closed [endoscopic] biopsy of large intestine – this code includes colonoscopy with biopsy

So I write back to Medicare. Really, I ask, is this what I have to do to find out how much you pay a hospital for a basic test? Read the rest of this entry →

Preventing Child Medical Identity Theft

January 29, 2013 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care

Along with being able to talk to providers and insurance companies from an informed standpoint, you will also benefit from knowing more about how criminals work to fraudulently bill others for various items including health care services. There has been a flurry of reports about a growing practice that’s pretty disturbing, especially to new parents. It involves criminals simply using children’s identities to bill medical services and other items to credit accounts.

Doesn’t The Government Check a Consumer’s Age?

You would think that children would be safe from identity theft because of their age. But, the reality is that with the complex database systems of many governments and private businesses, it’s often possible for criminals to commit fraud by using the Social Security number and other identifying information of a minor. At the same time, many of these efforts are successful specifically because nobody else is checking the credit account for a minor. Since a child can’t usually make purchases or access his or her credit, everyone figures the accounts will be dormant. What some unlucky parents are finding out, though, is that to many government agencies and businesses, one Social Security number is as good as another, and the issue of age does not factor into many of these fraudulent accounts. In some cases, criminals who open these kind of accounts can keep using them for months or even years.

What To Do About Child Identity Theft

Much of what consumer advocates recommend in terms of deterring child identity theft is the same as what you would do to prevent adult identity theft. Read the rest of this entry →

Tags: child identity theft, credit report monitoring, fraudulent medical bills, identity theft, insurance denials, medical bill crimes, medical bill help, medical bills, medical bills and identity theft, medical identity theft, prevent identity theft 1 Comment »

by HCSavvy

The $55,000 cat bite and other stories you won’t believe

January 24, 2013 in Hospital Bills

OK folks – we’re starting a new tab up there at the top of the page called, “You Won’t Believe This One….”

photo credit David Lazarus, his cat, Bear.

The inspiration is David Lazarus’ story about a cat bite that became infected and cost $55,000 to treat.

David tells the story and lays out the costs here.

Unfortunately, we hear lots of stories like David’s. And, there are lots of us who never even see the bills we pile up, so aren’t aware of how much we’re spending, and in some cases wasting, when we go to a clinic or hospital for care.

David, so glad your hand healed. We have to take issue with one claim in the your story…that the Affordable Care Act will get rid of “funny money” in health care…not a chance.

Protect Yourself from Medical Debt Overload with Self-Advocacy

December 27, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt

You or someone you know may be closing out the year with large amounts of medical debt even after insurance payments or what you thought were relatively minor surgeries or other procedures. In fact, you may feel like you’ve been hit by a blizzard by the sheer number of bills related to that one procedure. And they keep on coming.

One step you can do is confirm or validate the bill, especially if a lot of time has elapsed since the initial service. This simply means you want proof that you had the services rendered and do in fact owe the balance due. Under the Fair Credit Reporting Act, credit agencies are supposed to help consumers to ensure that bills are correct and fair before payment is rendered. But without good knowledge of these laws and taking the time necessary to investigate, you could end up paying much more than you owe. Here are a few other ways to stand up for yourself and your bottom line.

Keep Proof of Charges

The bad apples that pollute our debt collection environment may be operating on an entirely fraudulent basis. There have been many news stories of consumers receiving calls from phone bank operators, posing fraudulently as legitimate debt collectors. A tip off is that in many instances, the caller will fail to fully identify him/herself, their company, and the nature of the call. There are also reports that unprincipled companies are using ‘bread crumbs’ of financial data in order to manufacture phony debts that their workers demand payment for during outbound telephone calls. Collectors have been known to threaten litigation or other legal action without any legal basis as well as fail to provide written proof that a debt is owed when requested by the consumer.

One big part of your arsenal is the paper trail of charges, as well as Explanation of Benefits (or EOBs) that show whether or not the insurance company paid their fair share. Keep all of these documents on hand so that you can prove any overcharges and trigger an analysis by a credit agency.

Get Credit Bureaus In On the Action Read the rest of this entry →

Tags: collection agency, health insurer, medical bankruptcy, medical bill help, medical bills, medical debt 1 Comment »

Are Transparent Hospital and Medical Bills on the Rise?

December 3, 2012 in health care costs, Hospital Bills, Insurance Bills, Medical Care

News from an Ohio media news site indicates that “hospitals around the country” are trying to make their medical bills easier to read, citing the Healthcare Financial Management Association and a case study for the Cleveland Clinic, one site that has renovated the look of its paper bills.

Most of the changes focus on the idea that traditional bills just have too many lines and lack clarity about who has current responsibility for debt amounts vs. who has already paid. To this end, photos of new billing structures show that complicated sets of line items can be replaced with headings like “You Paid X on X Date” and “Insurance Company Paid X Amount.”

Changing the format for medical bills can help both you and your provider. Because when you can read a bill effectively at a glance, you are more likely to respond immediately to what you receive in the mail. Bills that are too cryptic often just end up getting thrown in the trash or added to the pile. This means the provider receives delayed payment or non-payment and you risk credit damage.

What These Medical Bill Improvements Don’t Address

Although it can be really helpful to make bills more readable, this still doesn’t address some of the most common challenges we encounter. Read the rest of this entry →

Tags: bills, costs of care, hospital bills, hospital prices, medical bill help, medical bills, out-of-network No Comments »

Blue Cross paid $1,650 for my $8,000 MRI

October 22, 2012 in health care costs, Hospital Bills

Well, this world of medical billing and costs is really wild.

I wrote a few weeks ago about getting bills that totaled just under $8,000 for an MRI (actually I got two tests while in the machine although I didn’t know this at the time)

Last week, the hospital sent me a more detailed bill that shows how much of what they charged Blue Cross actually paid. The total charge from Newton Wellesley Hospital (two tests plus fee to read the test) was $7,876. Blue Cross paid $1,650 (that’s $1,360 for the tests and $290 in physician’s fees).

Two things jump out at me.

1) the difference between what Newton Wellesley charges anyone who pays cash, and what they pay the largest insurer in Massachusetts is $6,226. Patients who pay cash for these tests are getting a really horrible deal if they don’t shop around.

2) the difference between what Blue Cross pays Newton Wellesley and what Blue Cross paid the cheapest place I found for an MRI, Shields, is not much. Read the rest of this entry →

3 Comments »

by Lee Ostrander

Hospital cost infographics

October 19, 2012 in health care costs, Hospital Bills, International Health Care

We already know about spiraling health care costs, but more information doesn’t hurt. Here is a comparison with other industrialized countries. The data is from a group affiliated with GWU’s School of Media and Public Affairs. The direct link is here. A shorter summary is here.

1 Comment »

by Virginia D Reiber

US Healthcare: an oxymoron

October 19, 2012 in Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt

It was very exciting to read about Amanda’s grass roots Twitter research. Amanda, you have started an activist conversation that we, the people, need to have. Comments from so many people on what Amanda started touched on a deep and growing moral and economic issue for which we must demand answers: loss of a job means loss of insurance, medical debt, loss of shelter and bankruptcy is not a rarity, unaffordable insurance premiums as the norm for the middle class, poor medical care for the disenfranchised, etc. I will add another observation. Do you know that if you have a very serious mental illness, have MassHealth, and need to be in hospital, you may wait 2-3 days in an ER for a bed? Or, if you have poor insurance, be treated in the ER, and when you are medicated and are saner, sent home? There also were a couple of comments from folks who wanted to know why the US did not have systems of care like The UK and Canada. People want to move to Vermont where there is a progressive move toward single payer healthcare for everybody. There IS an organization in the US committed to healthcare for all. PNHP was started by public health physicians in 1985!

Does anyone wonder why there is no political will in the US? PNHP started in 1985 with the inception of “managed care”, also viewed by many of us as for-profit healthcare. In this case “healthcare” is an oxymoron, isn’t it? Read the rest of this entry →

Tags: health insurance premiums, health plan, Insurance, mental health No Comments »

Share Your Medical Bill Story in 2012 Cost of Care Contest

October 15, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Member Stories

In listening to you, we’ve found, time and time again, that outrageously high medical bills are not a rare occurrence in this country. Many glitches and loopholes in today’s American health care system often leads to unexpected, mysterious billed amounts that threaten individual families and force many Americans to the brink of bankruptcy or worse. But too often, those with serious medical financial problems have no outlet for their rage and consternation.

Now, a non-profit consumer advocacy group called Costs of Care is sponsoring a contest that’s based on listening to the American patient – yes, you! Anyone who has ever had to deal with a surprise high-dollar bill for medical care is invited to participate.

The Costs of Care 2012 Essay Contest provides a listening ear for struggling Americans, and even a chance to win a portion of $4000 in cash prizes. Contest creators seek “anecdotes,” not policy positions, about big medical billing problems, and “high value healthcare decisions.” Judges include former U.S. Secretary of Health and Human Services Donna Shalala and other panelists, including doctors and health care officials. The deadline for this contest is November 15, so would-be contestants have just a short time to send in their stories of up to 750 words for consideration.

What’s behind the Contest

In soliciting stories from American patients, Costs of Care and other participants are seeking to put needed pressure on today’s community of medical providers. Read the rest of this entry →

Tags: 2012 essay contest, Cost of Care, high medical bill, medical financial problems No Comments »

Gold-plated stitches with a ruby stud

October 8, 2012 in health care costs, Hospital Bills

Remember that story about my colleague who got an $1134 bill from Mount Auburn Hospital for two stitches? Turns out that total didn’t include the physician’s charge: $364.

So those stitches were $799 apiece. My colleague cut her finger on the job and has been told she’s on the hook for these bills until the workers comp claim is approved. She doesn’t want to pay and have to deal with seeking reimbursement, but is worried now that the bills will go to collection. Messy. Expensive. Annoying, just for two stitches.

3 Comments »

Sticker Shock: an $8,000 MRI?

October 1, 2012 in health care costs, Hospital Bills

In June and July, I had a series of migraines. I chalked them up to stress and a lack of sleep but I went to see my doctor just in case.

I spoke to my colleague Sacha Pfeiffer about my attempts to shop for an MRI based on price. I ended up at a hospital I thought would be moderately priced. Last week, when I got a bill for $7,468 (plus an additional charge for reading the tests), I was stunned.

I only have to pay $25 of this and my insurer, Blue Cross won’t pay this total either. If you want to hear more about why this charge is so high, listen here.

Have you had a “sticker shock” moment with a health care bill?

3 Comments »

How to Protect Yourself from Higher Than Expected Medical Bills

September 28, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care

If you are insured and visit your local emergency room at a hospital network in your area of residence, you expect to pay the stated co-pay that shows on your insurance card, right? This is, in some senses, a reasonable expectation, but it’s not always what happens. News media outlets around the country have aggressively broadcast many cases where huge out-of-network charges for secondary providers have led to excessive medical billing amounts for patients who simply visited the wrong hospital at the wrong time.

The Problem: Hospital Network Staff Outsourcing

This major problem, that results in more out of pocket dollars than expected, really has to do with how hospitals staff. Hospitals may simply bring in outside doctors, nurses, technicians and other staff who aren’t effectively on staff at that facility, in order to help fully staff an emergency room or other hospital department. This is a convenient fix for hospitals, but what’s enraging is the idea that hospital administrators don’t think about the dramatic impact that out-of-network charges can have on patients.

What happens with out-of-network charges is that when outside physicians or other staffers happen to provide care to a particular patient, that patient is simply billed for the balance of that care because of an automatic insurer denial. Insurance companies won’t usually pay for the work of out-of-network professionals, but hospitals hire them anyway. Read the rest of this entry →

Tags: bills, health insurer, hospital prices, hospitals, Insurance, medical bill, out-of-network 2 Comments »

Will Medicare Changes Result in Better Quality?

September 3, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt, Medicare

As the price of health care in America keeps rising, you may be among those that are frustrated by the kind of generic approach taken by health insurance companies and government entitlement programs. The traditional fee-for-service format of health care reimbursement means that the best hospitals and doctor’s offices don’t get rewarded and the lower performing offices don’t have consequences. But, this is all likely to change with new Medicare rules that are slated to pursue more of a ‘meritocracy’ in the way that health care dollars get paid out.

New Medicare Rules

Reports from the Centers for Medicare and Medicaid Services show that Medicare is going to begin making some changes in the way that it reimburses health care providers starting late this year. In what Medicare officials call a ‘value-based purchasing’ program, Medicare will consider various aspects of a provider’s operations in setting the reimbursement rates for that particular office. Key factors will include observation of outcomes, or in other words, whether the procedures and services performed at an office actually help patients to recover from illnesses and improve quality of life.

Responses to the Changes

For you, this represents a major change and a big potential edge in making sure you get what you deserve for the money, especially when you have out of pocket expenses. On the downside, though, some providers are arguing that hospitals and offices in rural areas, or those with other significant disadvantages, may be punished unfairly. Read the rest of this entry →

Tags: health plan, Insurance, medical bill, medical debt, Medicare, quality No Comments »

How Much is Health Insurance Coverage Really Costing You?

August 30, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt, Medicare

Just when you think you have the health care business figured out, new reports come out showing even more dark details about how American patients are simply charged massive amounts of money for health care services on a pretty arbitrary basis.

The newest wrinkle in this story actually turns the conventional wisdom about payment for health care on its ear: where many assume that most uninsured patients get the highest bills, new reports are showing that, in many cases, the “cash-up-front” deals given to cash-paying patients may be as little as less than half of a contractually agreed price that the hospital would bill the insurance company. Why is this a problem? Because it means that many of those who pay high deductibles, premiums and coinsurance on a health plan may still be paying more for each service, visit or procedure than someone who doesn’t have any insurance at all. It also injects a huge monkey wrench into the now established idea that everyone needs health insurance to make health care affordable. On the flip side, if you have a high deductible but choose to self-pay a medical bill, how will you ever meet your deductible? This is particularly troublesome should you have a catastrophic event. Read the rest of this entry →

Tags: health plan, Insurance, medical bill, medical bills No Comments »

by Susan Mathisen

Figuring Out Your Medical Coding – What Doctors Are Hiding From You

August 30, 2012 in Hospital Bills, Insurance Bills

The curiosity bug bites us all from now and then, but especially so when something has to do with our own health. Imagine the frustration of having a piece of paper in front of you that tells you everything that’s wrong with you, what the doctors plan to do about it, and how much it’s going to cost you. Well, with medical coding, this frustration becomes a reality. Right there on your bill or summary or any other document given to you by your health care provider is the medical codes that hold the answers to all of the questions you have.

But medical coding is a locked answer booklet, oftentimes only decipherable by health care professionals and those within the medical coding profession. That’s because the American Medical Association (AMA) keeps a tight lid on what these codes mean, mostly so that they can keep their billing practices under wraps, but also to make money. But what can you do about this as a patient? Well, as it turns out, quite a bit. Let’s find out how you can figure out what your medical coding means.

What Is The Most Common Medical Coding?

Chances are the medical coding you’re seeing on your documentation is the Current Procedural Terminology, or the CPT for short. These medical coding numbers are assigned to each and every task, service, treatment or health care plan that a doctor provides for their patient (with the exception of those covered by Medicare). This includes:

Medical diagnosis
Surgical procedures
Diagnostic services
And just about everything else a doctor provides Read the rest of this entry →

by Mitchell Gavillion

10 Essential Questions To Ask During Any Hospital Visit

August 24, 2012 in health care costs, Hospital Bills, Medical Care

The hospital can be a scary, intimidating place, especially if you don’t spend a lot of time there. Depending on why you may have ended up in the hospital, there are certain questions you’ll want to ask your doctor and the medical staff.

Are all the signs normal? You’ll want to know about all your vital statistics. How is your blood pressure, body mass index and breathing?
Details about your problem: Ask the doctor treating you what may be causing the problem that forced you to visit the hospital. Could there be more than one issue affecting your health? Being kept in the dark can help compound your stress and make visiting a hospital even more severe.
Learn more about the tests: Some of the testing done in a hospital can be uncomfortable and invasive. Find out first how accurate the tests are for diagnosing an issue. How safe are the tests you’ll need to undergo and what could some of the side effects be?
Get the facts after diagnosis: If you are diagnosed with a serious condition, find out what the next course of action will be. Ask about the long-term outlook and what treatment options are available.
Ask about each treatment option: Find out what the pros and cons of each treatment option available to you. What are the risks associated with each treatment and how do they weigh against the benefits?
Get the facts about pricing: Read the rest of this entry →

2 Comments »