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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 →

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 →

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 →

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 →

Plan Ahead for International Travel Medical Bills

November 2, 2012 in health care costs, Health Insurance, Insurance Bills, lifestyle, Medical Care, Medicare, Member Stories

You may be closing out 2011 with a holiday trip, domestically or internationally. If you plan to leave the country, you may want to consider the following when it comes to your health:

  • You may not have health insurance coverage for illnesses or injuries that are treated abroad, even if you have US based medical coverage. Confirm with your benefits administrator.
  • Generally, Medicare does not provide coverage for hospital or medical costs incurred abroad, however, rare circumstances may be covered.
  • AARP can assist with obtaining foreign medical coverage and offers valuable travel tips.
  • US consulate personnel will help you locate health care providers and facilities and even contact family members, if necessary.
  • You can purchase travel insurance that covers health care needs and pays for medical evacuation if you need to be transported back to the US for treatment.

Obtaining medical treatment in another country can be expensive and a medical evacuation can cost over $50,000. Plus, you may encounter challenges with deciphering charges while abroad. Be vigilant, prepared, and follow the same self-advocacy steps you would while receiving medical care in your home state.

If you choose to purchase medical expense coverage while travelling abroad, double check you’ve carefully researched the following:

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 →

Practice is Proactive in Patient Relationships

August 25, 2012 in health care costs, Health Insurance, Medical Care

The Commonwealth Fund’s 2010 study found that almost 50% of US adults were either underinsured or uninsured.  This is a 7% increase from 2007 for the underinsured population. It used to be that having coverage was simply enough. Today, however, having the right type of coverage and amount are key factors in choosing a plan. What happens when you don’t have coverage for a specific procedure? One forward thinking practice in the Chicagoland area takes the time to explain your options and provides the cash discount rate – up front. Before you even ask. That’s mightily refreshing given the lack of communication in many healthcare organizations. And, it’s a win win for both parties. The practice receives a bill paid in full without expending additional dollars in the collections process and the patient is educated a little bit more on how the billing and insurance process works. Let’s hope that more practices implement this customer service level in the near future.

Challenging Rejected Health Insurance Claims

August 5, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt

According to the AHA (American Hospital Association), 87% of hospitals expect bad medical debt to continue to grow.  And it’s no wonder with situations like a very common one experienced by patients across the nation. You are seen by your healthcare provider for a service or procedure that should be covered under your insurance plan per plan benefits. However, when the Explanation of Benefits is received from the insurance carrier, charges have been denied for coverage. What happened?

Reimbursement is based on a few key areas including plan benefits and coverage period, medical necessity, correct patient information, diagnosis code, and procedure/service code (CPT), etc. An incorrect key stroke can cause your claim to be rejected. Or, an erroneous code can result in zero dollars paid. What can you do?

Begin by appealing the rejection to your doctor and the insurance company. As described above, it may have been a simple clerical error that caused charges to be dismissed. In other situations, you want to confirm that the CPT and diagnosis codes are cross referenced. What may have happened is that the CPT code did not support the diagnosis or the reverse. Codes are chosen based on the physician’s notes, documentation, and national coding guidelines. Sometimes, the CPT code may not be specific enough or it may have incorrectly described the level of care. Most insurance companies have their own unique process and timeline for appeal submissions.

If you’ve exhausted your appeal efforts and your claim remains unpaid, you may want to file a complaint with your state’s health insurance commissioner and or enlist a medical bill advocate to navigate the process for you. Whichever route you choose, be persistent, professional, and follow through.

Managing High Health Care Costs on Your Family’s Budget

July 22, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt

Recent news on the costs of health care, in the U.S. and around the world, is focusing on what experts call “double digit levels” of annual increases. This is bad news for us, and troubling for the country as a whole. What it translates to is annual increases over 10%, where health care costs could conceivably double in a decade. Since this kind of price spike has been going on for a while already, many American families already consider major medical care to be priced above their ability to afford it.

Who Pays the Bill? 

Part of the particular desperation that has surrounded the American medical industry in the past few years has to do with who usually pays the bill.

In the past, employer group plans provided coverage for the majority of Americans. A few decades ago, this model was built on stable, long-term contracts between workers and companies, where those who stayed loyal to a business could expect to keep a job for life. Also, employers paid a major part of all premium costs.

In the present, however, we’ve felt the rise of health care prices. First, employers started to lower the premium amounts they were willing to pay. As jobs went overseas, employers laid off workers. Then, as the economy grew weaker, more lost jobs. An unemployment rate of over 10% means much more than lost wages: it means that many thousands of American families are suddenly left without coverage.

Meanwhile, the group plans that are left often do not pay the majority of premiums and often include high deductibles, which are also extremely expensive for the average family. In fact, some employers hardly pay anything toward premiums at all, while others provide “mini-medical” plans or other virtually useless coverage, or move full-time positions to part-time and thus avoid offering plans.

What Can You Do? Read the rest of this entry →

Medical Claim Error Rates Decline According to Latest Report Card

June 24, 2012 in health care costs, Health Insurance, News

News from the medical industry shows that the American Medical Association or AMA is working with private health insurers to lower the rates of medical billing errors within the American healthcare system. For a while now, the AMA has been talking about a collaborative effort to make medical billing more efficient, and it seems that this initiative is starting to pay off, according to this year’s National Health Insurers Report Card, an annual report released by the AMA to document national trends.

Overall Error Rates for Medical Claims

The new report shows inaccuracies for private health insurer payments dropping from nearly 20% in 2011 to just under 10% in 2012. The AMA claims that this 50% reduction has saved the industry over $8 billion, and that there’s a lot more potential for improvement. In a press release this month, AMA Board Chairman Robert M. Wah is quoted as saying that first-time accuracy in medical claim payments “saves precious healthcare dollars and frees physicians from needless administrative tasks” – that’s the idea behind these sorts of efforts to increase accuracy. These improvements help physician offices manage revenue cycles, while they also help you to understand your financial responsibility and contribute to greater transparency in the healthcare market.

Other Numbers

The National Health Insurer Report Card also provide some other assessments of this year’s trends within the medical industry. While the report shows improved response times for medical claim payments, and indicates greater transparency by health insurance companies, it also shows that medical claim denials are now on the rise. The AMA sites a prior decline between 2008 and 2011 that was reversed this year with an increase of nearly 70%. This increase, according to the AMA report, was across the board, as all major insurers declined many more claims than they had the previous year. Denials will be an issue that third party medical advocates and others will continue to evaluate in order to make sure that you are getting a fair shake when it comes to your healthcare costs.

We face a lot of challenges in identifying and controlling our health care costs. Keep informed on what’s happening in the health care industry as it affects you.

Are You Being Treated by a Subcontracted Doctor?

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

A recent story from Dayton, Ohio, caught our attention, where according to news reports, some patients remain responsible for emergency room charges when a hospital happens to ‘subcontract’  doctors who may not accept health insurance at all. This adds another layer to the oftentimes confusing in network vs. out of network debate. In many cases, especially in an emergency situation, patients who visit a local hospital or facility may experience unexpected costs after they are cared for by a doctor who may not be ‘in their network’, even if the facility itself is listed as an in network provider. There’s been a lot of discussion whether this, which may seem deceptive, especially to those without specialized knowledge in the medical billing and health insurance field, is fair. In fact, state officials, like in New York, are  looking to pass legislation which mandates better transparency for out of network charges. Taking the time to understand your health insurance plan and what defines a covered provider or facility can save you hundreds if not thousands of dollars in non-covered charges.

It seems providers tend to respond to these scenarios in two ways: Some indicate they will change their policies to include more transparency while others claim to be bound by federal laws that do not allow them to reveal to patients whether an on-call doctor or a physician on shift will accept their insurance or not.

We find the second argument to be completely unacceptable at face value. In fact, it’s reasonable that consumer advocates would expect state regulators to crack down on these well documented examples of seemingly unfair provisions in delivering medical services. It’s not outside the realm of possibility that a patient facing bankruptcy after a bill like this would have a basis for legal appeal, especially as new legislation is introduced and passed. It’s vitally important that you discuss your options and ask questions before treatment to minimize impact to your financial future. How prepared are you in the event of an emergency room visit?

Beware of Balance Billing in Hospital Bills

May 12, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills

Balance billing occurs when a healthcare provider bills a patient for some or the entire amount that should have been declared an insurance discount (contractual allowance). The fact that Prime Healthcare Services in California recently settled a suit for $1.2 million and discontinued the practice suggests that this is a problem. In fact, several states have statutes that prohibit balance billing.

How do you tell if you’ve been balanced billed? First, you have to determine if your treatment was performed by an in or out-of-network healthcare professional. Then, you have to check your EOB (Explanation of Benefits).

In- Network

Check an erroneous charge simply by seeing if the bill for the service exceeds the amount on the EOB. If it does, let your insurance company know and let them handle it.

Out-of-Network (OON)

There are two scenarios:

  • If you have an OON benefit, the OON deductible and co-insurance will apply first. The insurance company pays the balance above that like always. However, if the provider billed you for more than the deductible and co-insurance you may be the victim of a scam. Check the EOB. Did insurance pay the provider? If so, report it. It’s a scam and it is wrong.
  • If you do not have an OON benefit and accidentally got treated by the provider, tell them you want to be treated like an uninsured patient. A standard discount will be applied.

When in doubt, check with a medical bill advocate.

Past Due Medical Bills: When Do I Have to Pay?

May 5, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt, Medicare

Have you received a medical or hospital bill with no clear due date? This can be because of how bills are laid out or because of design issues. Typically, a bill or patient statement will show medical debt as 30, 60, or 90 days past due, providing the kind of urgency that can make you drop a check in the mail. Bills may also be labeled “second notice” or “third notice” to show that the biller has already tried to contact you. But, all of that doesn’t always tell you what you need to know: how long you have to pay before the bill goes to collections. There are several reasons you may choose not to pay your medical debt right away including having a lot of bills or long-term debts to juggle. Prioritizing which ones to pay can take precedent to stay afloat. And, some billing statements require real, actionable steps while medical bills seem to be written in some strange, esoteric language.

Medical Debt Collection: Common Practices

Every medical provider has their own system for handling past due bills. Some are quicker than others to send a past due bill to collections. Many have different billing systems that represent debt in different ways. Some may be explicit about a due date, others will not. In some cases, when patients call, the medical office admits that they don’t even know the exact date when a bill will go to collections. That’s what motivates many experienced consumer advocates and others to recommend “playing it safe” and promptly paying all past due medical bills aged longer than 30 days, which is a common grace period for payments.

Some patients, though, will make active attempts to talk to providers. Those who pick up the phone can often get on payment plans that will make due dates and everything else much clearer, while allowing for deferred payment according to the patient’s finances. Some can even qualify for charity. In many cases, it’s this direct communication which can yield benefits for both parties: you know where you stand and your provider receives data on how and when you are likely to pay a particular bill. It’s a win-win, and that’s why when it comes to vague patient statements, the direct approach is often best. How do you promote open communication with your provider on past due medical bills?

Overused and Unnecessary Medical Procedures

April 28, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt, Medicare, Member Stories

Nine physician specialty societies are each reporting a top five list of commonly used procedures that are often unnecessary. These societies represent 375,000 physicians across the country.

Some of the procedures cited include:

  • Brain scan after fainting (without other relevant symptoms)
  • Antibiotics for sinusitis (while typically resolving itself in two weeks, 80% of patients are prescribed antibiotics. CT scans are also usually unnecessary.)
  • Admission and pre-operative chest X-rays (routine X-rays are not needed.)
  • Colonoscopies (not recommended but once a decade.)
  • Cardiac stress tests (they do not need to be part of a checkup for a healthy adult.)
  • Lower back pain (unless another ailment is suspected, X-rays are not needed in the first six weeks.)

Unwarranted testing can lead to stress, over treatment, higher medical bills, and even unneeded invasive procedures.

In fact, the natural tendency to screen for heart disease prior to having any symptoms, like getting a stress test as a 50th birthday present, hasn’t “panned out,” according to a preventive cardiologist at Northwestern Memorial Hospital.

Study members suggested that patients and doctors have to thoroughly discuss any tests/procedures even if they are suggested by patients because they are not always needed.

25 Million Americans Underinsured Including Middle and Upper Income Families

April 18, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt, Medicare

As current government initiatives wrestle with the issue of millions of uninsured Americans facing potential medical bankruptcy, new studies are revealing that it’s not just the uninsured who are at risk. The issue of underinsured American individuals and families is becoming a major part of today’s healthcare conversation and alerting many more Americans to the dangers that they face, even if they have access to affordable health insurance policies.

Current statistics show a startling trend, where being underinsured is becoming a common way to fall into extreme medical debt and eventual bankruptcy or bad credit situations. Research by the Commonwealth Fund that appeared in recent industry journals shows that America’s underinsured community has doubled in the past four years to over 25 million people. While the highest number of underinsured Americans are in the income range below the poverty level, research shows that middle and upper income families are being affected in larger numbers each year. Research also shows that some individuals with what others would consider healthy annual incomes are still very likely to become underinsured in the immediate future.

In general, being underinsured has to do with the cost of one’s medical bills against that person’s annual income. Read the rest of this entry →

When is a Medical Bill Sent to a Collection Agency?

March 5, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt

A recent article in the Chicago Tribune’s March 4, 2012, issue “Small, Paid-off Medical Debt Can Mar Credit, Upend Financing for Unknowing Americans” highlighted how quickly a pristine credit can plummet when unexpected medical bill balances show up on credit reports including previously paid off medical debt. According to the Commonwealth Fund, 30 million Americans were contacted by collection agencies in 2010, an increase of over 25 percent from 2005. And, the Access Project, a research group funded by health care foundations and advocates of tougher laws on medical debt collectors, estimate that over 3 million Americans who have paid off their debt in full still have their balances appearing on their credit reports. Most of the collection actions are attributed to medical bills with the majority of outstanding balances under $250.00.

Medical bills are sent to collection agencies quicker than you think. In fact, it is common to receive a bill within a few days or so of your procedure or hospital stay and the clock starts ticking. So, what can you do to minimize your account from being turned over to a collection agency?

Tips on avoiding medical debt

January 13, 2012 in Medical Debt

man with thought bubble: "Wait a minute, I owe that much for a few medical procedures? How can I afford to pay this bill?"

A few weeks ago you visited your doctor. Maybe you had a few tests run. Maybe you had an out-patient procedure done. Or maybe you even had a short stay in the hospital.

Then comes your bill. And it’s far more expensive than you’d expected. Now what?

Many people are surprised that the price tag on their medical bill isn’t set in stone. Between financial assistance programs and negotiating directly with your provider, there are strategic ways to avoid knocks from the collection agency.

Choices, Choices

First things first: You should deal with your medical bills as soon as possible. You have several options:

Option 1: Not paying

If you’re uninsured or financially struggling, the idea of paying a costly medical bill can be daunting. But not paying isn’t so much an option as it is a danger. Most unpaid medical bills will eventually be sent to a collections agency, and collectors often report medical bills to credit bureaus. If you want to spare your credit score a beating, move onto options 2, 3, or 4.

Option 2: Apply for financial assistance Read the rest of this entry →