plus the tax benefit of contributing to an HSA is pretty sweet
IRS announces 2024 HSA, HDHP limits
- Thread starter Northeast Agent
- Start date
- 6,462
@Deborah Armstrong
(Caveat, I am not an insurance agent)
You have made two posts in this thread that generated some anger on my part. This is one of them.
The way I read your post says you are suggesting there can be 3 different types of errors in a medical provider's bill.
(insurance carrier) Repricing errors
Incorrect (medical provider) pricing
Incorrect coding
You also suggest that "you" (presumably the average user of American medical services) can catch these mistakes by reviewing "your" bill.
That is pretty much impossible.
That is why I kept pushing you about the post.
This answer:
Pretty much suggests I was right. You are unable to tell me how to do it. You say you would have to see the actual bill, but I don't think you could do it either, even with the bill in hand.
The reason is that determining "correctness" in each of those situations involves using two or more pieces of information while only one or none of the needed pieces of information are present on a bill.
A common piece of needed information for all three is the Medical Practice's billing code(s) for service provided. I see the codes present on some of my bills, but not all. (or possibly I may be confusing statements with bills).
To determine correctness of the Medical Practice's billing you are going to need the billing code plus the Medical Practice's billing table. The billing table will not be present on the bill.
(And I highly doubt you could get it for any "off bill" comparison.
To determine correctness of the Insurance Carrier's repricing, you are going to need the Medical Practice's billing code plus the insurance carrier's repricing table. The repricing table will not be on the bill.
To determine correctness of the Medical Practice's coding of the service(s) provided you would need the actual billing code plus very detailed verbal description of all services provided, the actual billing code tables and the technical knowledge of how properly to apply the verbal description of service provided to the table to obtain the correct billing code. The billing code tables are not on the bill. The average person is not going to be able to look at the bill and determine incorrect billing codes. There may be certain areas where specialists, such as insurance agents, have memorized a few codes and can tell for a few very specific situations if the codes are incorrect.
An example would be experienced insurance agents answering questions from clients with plan N about insurance carrier payment issues around Physical Therapy Services.
To repeat a comment above, I am not at all surprised you can't tell me how to review my bill(s) for errors and I doubt you would be able to do it either.
(Caveat, I am not an insurance agent)
You have made two posts in this thread that generated some anger on my part. This is one of them.
The way I read your post says you are suggesting there can be 3 different types of errors in a medical provider's bill.
(insurance carrier) Repricing errors
Incorrect (medical provider) pricing
Incorrect coding
You also suggest that "you" (presumably the average user of American medical services) can catch these mistakes by reviewing "your" bill.
That is pretty much impossible.
That is why I kept pushing you about the post.
This answer:
Pretty much suggests I was right. You are unable to tell me how to do it. You say you would have to see the actual bill, but I don't think you could do it either, even with the bill in hand.
The reason is that determining "correctness" in each of those situations involves using two or more pieces of information while only one or none of the needed pieces of information are present on a bill.
A common piece of needed information for all three is the Medical Practice's billing code(s) for service provided. I see the codes present on some of my bills, but not all. (or possibly I may be confusing statements with bills).
To determine correctness of the Medical Practice's billing you are going to need the billing code plus the Medical Practice's billing table. The billing table will not be present on the bill.
(And I highly doubt you could get it for any "off bill" comparison.
To determine correctness of the Insurance Carrier's repricing, you are going to need the Medical Practice's billing code plus the insurance carrier's repricing table. The repricing table will not be on the bill.
To determine correctness of the Medical Practice's coding of the service(s) provided you would need the actual billing code plus very detailed verbal description of all services provided, the actual billing code tables and the technical knowledge of how properly to apply the verbal description of service provided to the table to obtain the correct billing code. The billing code tables are not on the bill. The average person is not going to be able to look at the bill and determine incorrect billing codes. There may be certain areas where specialists, such as insurance agents, have memorized a few codes and can tell for a few very specific situations if the codes are incorrect.
An example would be experienced insurance agents answering questions from clients with plan N about insurance carrier payment issues around Physical Therapy Services.
To repeat a comment above, I am not at all surprised you can't tell me how to review my bill(s) for errors and I doubt you would be able to do it either.
On very rare occasions clients call to ask why a bill was not paid, or not paid in full.
Most of the time the Part B deductible had not been satisfied. Those are easy to spot if they can log into their Medicare account and see when/if the deductible is credited.
Sometimes the claim is denied because the service was not a covered charge. More often than not it is a denied lab charge. When that happens the first thing I ask is, "Did you sign an ABN form?".
Usually they don't remember but if it is important to them, they will have to dig through their files or call the provider and ask for a copy.
This happened with one of my wife's charges. She did not have a copy of the ABN, the provider didn't want to research it, so we filed a Part B appeal. It took several months but Medicare finally reviewed the denial and indicated "proper disclosure was submitted to Medicare by the provider" explaining that if the claim was denied we would be responsible for payment.
The lab kept dunning us for payment while we were waiting on the appeal. Eventually they coughed up a copy of the ABN about the same time we heard from the appeal.
The only rub was the lab billed me $210 for a test that could have been performed at a lab for $40 cash.
It is almost impossible for anyone other than the beneficiary to review claims and determine if they were overcharged.
FWIW, there are companies that will review claims for a fee and tell you if you have been overcharged. The fees are usually several hundred dollars and the claim must exceed a floor before they will agree to help you.
Most of the claim reviews involve hospital inpatient where they will ask for a detailed bill for all services ordered and check it against the master bill to see if the service(s) was/were actually administered. It is fairly common for med's to be ordered "just in case" but never actually administered and were returned to the pharmacy but never removed from the final bill.
Claims often pass through a Clearinghouse before the claim is actually submitted to the carrier for payment. This link explains in detail.
https://clearinghouses.org/
"The average error rate for paper claims is 28%. But using the right clearinghouse can reduce that to 2-3%."
I doubt an agent, or patient, has the skill set to perform a true audit of medical claims.
Most of the time the Part B deductible had not been satisfied. Those are easy to spot if they can log into their Medicare account and see when/if the deductible is credited.
Sometimes the claim is denied because the service was not a covered charge. More often than not it is a denied lab charge. When that happens the first thing I ask is, "Did you sign an ABN form?".
Usually they don't remember but if it is important to them, they will have to dig through their files or call the provider and ask for a copy.
This happened with one of my wife's charges. She did not have a copy of the ABN, the provider didn't want to research it, so we filed a Part B appeal. It took several months but Medicare finally reviewed the denial and indicated "proper disclosure was submitted to Medicare by the provider" explaining that if the claim was denied we would be responsible for payment.
The lab kept dunning us for payment while we were waiting on the appeal. Eventually they coughed up a copy of the ABN about the same time we heard from the appeal.
The only rub was the lab billed me $210 for a test that could have been performed at a lab for $40 cash.
It is almost impossible for anyone other than the beneficiary to review claims and determine if they were overcharged.
FWIW, there are companies that will review claims for a fee and tell you if you have been overcharged. The fees are usually several hundred dollars and the claim must exceed a floor before they will agree to help you.
Most of the claim reviews involve hospital inpatient where they will ask for a detailed bill for all services ordered and check it against the master bill to see if the service(s) was/were actually administered. It is fairly common for med's to be ordered "just in case" but never actually administered and were returned to the pharmacy but never removed from the final bill.
Claims often pass through a Clearinghouse before the claim is actually submitted to the carrier for payment. This link explains in detail.
https://clearinghouses.org/
"The average error rate for paper claims is 28%. But using the right clearinghouse can reduce that to 2-3%."
I doubt an agent, or patient, has the skill set to perform a true audit of medical claims.
Deborah Armstrong
Expert
- 83
This isn't an insurance agent's job to know how to read codes and what they mean. However, I can remember when my first child was born and couldn't believe how high the bill was for our newborn. We made phone calls and after a lot of calls and documents sent to us, we saw how much we were being charged. Almost 30 years ago we were charged $5 for a single diaper and other ridiculous charges. The second child we brought everything we needed and refused anything they tried to pass off as freebies. Nothing is free.
When you want to know what you are being charged, it is a matter of finding out who handles the bills and codes them and ask for explanations of the codes and charges. You can call billing at the health facility and find out what your procedure is coded and call your insurance to see if everything is accurate. That is the simple answer. It can be much more than that. It depends on the situation.
Much has changed in 30 years. Paper claims are almost non-existent. Claims are coded in the computer, often by the provider, at least in larger practices. Medical transcription is usually scanned from the provider notes.
On the other end claims are adjudicated by computers. Programs match the ICD-10 codes against the CPT4 treatment codes and either paid or kicked out if the treatment does not match the diagnosis.
Par providers can lose their contracts if they offer discounts that are lower than the carrier would pay. Of course if a claim is never filed the provider can pretty much do what they want with impunity.
Provider billing data, discounts, etc is considered trade secrets and there can be repercussions for disclosing that information.
On the other end claims are adjudicated by computers. Programs match the ICD-10 codes against the CPT4 treatment codes and either paid or kicked out if the treatment does not match the diagnosis.
Par providers can lose their contracts if they offer discounts that are lower than the carrier would pay. Of course if a claim is never filed the provider can pretty much do what they want with impunity.
Provider billing data, discounts, etc is considered trade secrets and there can be repercussions for disclosing that information.
- 6,462
You and I may be viewing the term "charge" differently.
Just because you (or I) have the view that a charge ( ie: $5 for a diaper ) is unreasonable, amoral, or unaffordable; does not mean it is incorrect.
I think you are thinking in terms of negotiating correct charges to adjusted charges that the person negotiating considers reasonable, moral, or affordable.
Assuming that I expect charges to be covered by insurance and I expect the service provider to be in network with the insurance carrier, when I want to know what I am being charged for healthcare services from a provider, I look at the EOB provided by the insurance carrier for the service(s) in question.
I try to make it a practice not to pay a bill until I can match it to the EOB. If I don't like the EOB, I am likely to have a problem because, in my experience, providers will pursue collecting (up to and including using outside collectors) the balance the EOB shows I owe. Appeals to the carrier are a very iffy process and the provider may be unwilling to wait until an appeal process is concluded to take forceable collection action.
Last edited:
- 6,462
This may not be possible in all situations.
If I am correctly remembering the way I worded my question,
In the past I asked in another thread about bringing one's own medicines to the hospital to avoid hospital charges for user administered meds. The forum responses suggested that would not be possible because of the Hospital's liability concerns and their need to be completely in control of all meds during the recovery phase (even though some of those meds were "user administered
": OTC Pain Meds, Heart Meds, and Allergy Meds.User administered as in:
The nurse or LPN strolls in with a big smile and a tray full of plastic bottles accompanied by a glass of water.
Nurse extracts pill from one bottle, puts it in a little plastic cup, carefully hands me the cup and the glass of water. "Take this!" CaChing. $50 on the cash register. ($50 a round, give or take number.)
Repeat med process with Med 2. CaChing. another $50 on the cash register.
And so-on, x times a day.
AND, in 5 years, at various facilities of this same local hospital, the "self-administered" medication charge has doubled from approximately $25 per dose to $50 per dose. While the EOB does not show the specific meds, nor do I remember them now, after comments from @kgmom219 and @somarco 5 years ago, I can look at the EOB and know exactly what happened.
- 6,462
Self administered meds. See my comment in post 20 above.
Re coding: MSN's do not use the same letters consistently for a particular "notes description".
They just start with the letter A for the first page, use up however many letters it takes for all the descriptions, then start with the next letter on the next page, using all new letters for the descriptions, even if some repeat.
You should be able to see that happening in the MSN you had the L and O codes on, look at some of the earlier pages, for example you should see some of the same footnotes on page 2 as on page 1, but with different letters than on Page 1.
After the Capital Letters are used up, they continue with lower case letters. My longest EOB went to "w" or "x" (lower case) so I don't know what they use on a very long MSN after the lower case z.
Deborah Armstrong
Expert
- 83
This may not be possible in all situations.
If I am correctly remembering the way I worded my question,
In the past I asked in another thread about bringing one's own medicines to the hospital to avoid hospital charges for user administered meds. The forum responses suggested that would not be possible because of the Hospital's liability concerns and their need to be completely in control of all meds during the recovery phase (even though some of those meds were "user administered
User administered as in:
The nurse or LPN strolls in with a big smile and a tray full of plastic bottles accompanied by a glass of water.
Nurse extracts pill from one bottle, puts it in a little plastic cup, carefully hands me the cup and the glass of water. "Take this!" CaChing. $50 on the cash register. ($50 a round, give or take number.)
Repeat med process with Med 2. CaChing. another $50 on the cash register.
And so-on, x times a day.
AND, in 5 years, at various facilities of this same local hospital, the "self-administered" medication charge has doubled from approximately $25 per dose to $50 per dose. While the EOB does not show the specific meds, nor do I remember them now, after comments from @kgmom219 and @somarco 5 years ago, I can look at the EOB and know exactly what happened.
I was actually requested by the hospital to bring in my mother's seizure medication because they didn't carry it at the hospital. Two out of three hospitals in my area did not carry Briviact because of the expense, so at times if your hospital doesn't carry a certain medication and it cannot be substituted you can bring it in.
- 10,330
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