My S went to urgent care after his cat scratched his eye (his employer would not let him off work early to see an eye doctor). They did a stain, looked at it under some sort of scope, and put in a couple eye drops. The bill came this past weekend … $114 for the “new patient” visit, $25 for “evening,” and $245 for “eye flour alcain / patch” (reduced from $300 due to insurance allowance). The $245 procedure was coded as 66030. Since I thought $245 was a bit pricey for the procedures performed, I looked up billing code 66030 - it’s for an eye injection, which he did not get. I talked to my D, who has worked in EMR set-up/launch, and she told me to double-check … their system may be incorrectly set up. The more I Googled to find out what the correct code might be, the more I read that the procedures he had done maybe should have been considered part & parcel to the office visit (but maybe that doesn’t apply to urgent care situation?) - but definitely did not fall under the code they used. I called the billing office, and it all started out nicely - I asked that the charge be reviewed to make sure it was correct. The more we talked, the more upset I got. The woman seemed to believe there could not possibly be a mistake (“That’s what the doctor circled”), and … this made me really mad … “It all goes to your deductible, anyway.” ARGH!!! Um, just because the insurance company is paying the charge doesn’t mean I think overcharges are okay (and with a high-deductible plan, I am not keen on paying more than I need to pay, either). I told her that I wanted her to talk to the doctor to make sure everything was indeed correctly charged, and to make sure the billing code that it was paid under was actually the correct code. I told her that I did not want to pay more than I really should pay, but that if they determined it to be correct, I would pay the full amount … and I said that my son would never set foot in that urgent care again, because $245 to look at a scratched eyeball (in addition to the office visit and night premium) was absolutely ridiculous. She called back 10 minutes later, stating that the charge was correct, but that they would remove it … and she made a big point of saying that they would be contacting the insurance company to remove the charge, so it would not apply to my deductible. I told her that I fully expected them to do that.
So, can anyone here provide some insight into the very mysterious world of medical billing? Am I off-base in questioning why a particular code was used when it didn’t seem to fit? Am I off-base in thinking that there could be mistakes in the billing system set-up? I was willing to pay whatever charge was appropriate, but I wanted to make sure I was actually charged appropriately. I’m still mad. Talk me down, please.
No, you are not off base questioning the billing! Mr. was billed 2 office visits for one! Because it was a routine check, it was billed as such. Because the doc refilled his prescription, it was also billed as a problem visit (or whatever it was called). And because the insurance does not cover two visits to the same office in one day, the more expensive one was not covered! I was furious and had Mr. call the office. They gave him a big runaround (same story - doc cannot be wrong), so he called his benefits administrator. A week later we got a new bill - the “problem visit” charge was removed. Even if it is “insurance money”, we all end up paying for it.
Very large company with no actual “benefits administrator,” unfortunately. At this point, I am satisfied - I don’t have to pay the charge. It just irks me that the urgent care facility charged the way it did and was so miffed that I questioned them. Really, I was very, very nice at the start of the conversation (not so much by the end, although I did apologize - she didn’t seem to want to hear it, though).
I hate dealing with doctor’s offices and insurance. For my physical, my doctor orders certain blood tests, some of which are covered without deductible according to ACA, some of which are not. But then my insurance company bundles 3 tests to create a new code that isn’t covered, even though the tests were ordered individually and billed by the lab individually. At least one, if not 2, of those tests are covered without deductible under ACA. I’ve had to appeal it each of the last 2 years. Last year they paid on appeal; this year they didn’t. It’s incredibly frustrating. DH and I have had other issues with doctor’s offices not understanding (or caring) how important coding is to get the claim processed correctly. I’ve also had a doctor’s office tell me that something wasn’t paid because it went to my deductible, when it shouldn’t have gone to deductible if it had been coded correctly.
“Benefits administrator” is a code word for a designated person in HR who deals with insurance issues. You bet they wanted to get this straightened out!
Out of curiosity, kelsmom, did he go to an IHA urgent care center? It sounds exactly like how their pricing scheme is set up.
If it is IHA, I can’t count the times I’ve had to challenge their charges. You’re definitely not off-base in challenging it and if it is IHA, I’d recommend never going there again. I had so many issues with them that I ended up transferring all of my doctors to another system.
I’ve come to the conclusion that many medical billers just don’t care. They are overworked, underpaid, and often (at least in that health care system) temporary workers.
Oh, and as an aside, I could totally see that procedure being billed that high. I finally got my EOB from BCBS and my half hour infusion treatments “cost” 12k each. No, the medicine doesn’t actually cost that much but that’s what they charge because they can get away with it.
It was an independent facility, and S actually really liked the staff and doctor. He was all set to go back again if he needed an urgent care, but this really turned him off.
BunsenBurner, this particular company is a hot mess when it comes to benefits. They cut back staff so much that no one is in charge of anything … “go online to figure it out” is the recorded message. That said, they are self-insured, so they SHOULD want to know when things like this happen. I have a friend who is an exec for another type of benefit at the company, so I will talk to her to see if she knows anyone I can talk with about it.
I used to work in medical billing (and have a lot of familiarity with coding, too). I find errors all the time in healthcare bills I get. I check them all carefully – errors can happen at so many points in the process (doctor, coder if it is a separate person, billing system, insurance company). I think most people just pay what they are billed – I have an MBA and all this experience, and feel bad for people who don’t have that background. @kelsmom, maybe they didn’t have the code they should have on their form if they see it infrequently, so the doc picked the closest thing. That is a form design issue – yet another source of billing issues.
“It was an independent facility, and S actually really liked the staff and doctor. He was all set to go back again if he needed an urgent care, but this really turned him off.”
Amen and sigh. We left a good dentist because his billing office was gawdawful.
I check my bill carefully. I remember when D was hospitalized as a toddler and she was charged $5 per baby aspirin and given over 100 of those pills as part of her therapy. I called billing and said there must be some mistake and got them to change it. The conversation remained friendly. Insurance paid it all, but it just seemed horribly inflated to me.
I also remember getting a bill when D was 2 years old, for her birth. I asked the hospital for an itemization, since I had no copay for S’s Bill when he was born just 2 years before D and we had same insurer. The hospital said charges were so old they couldn’t itemize and we should just ignore and forget the bill because I said I was sorry I couldn’t pay without itemization. The conversation remained friendly.
@kelsmom - you were right to check the bill and to call and question the charges. It’s a chaotic world out there and they will bill for everything they can, sometimes hoping insurance will at least pay 1/2 of it, sometimes hoping that you will pay it all.
D’s fiancee was billed more than $1000 for bloodwork that his doctor insisted was in network and covered. He called to complain and hasn’t received another bill yet. The lab work was done in house, which is fishy to me.
My other D was charged an by an outpatient surgery center for more than $20,000! They said that they would take whatever the insurance paid but wanted the check sent to us and signed over to them. If insurance didn’t pay, the bill was $20,000+ (and this was about 3 hours and regular surgery - not lasers or proton beams or whatever).
I got the check, signed it over to them and THEY CASHED IT and then kept calling me and harassing me that it wasn’t paid. Total incompetence and it took over a month to straighten out. They are out of business now.
I win this thread: When my son was born 31 years ago, the hospital billed the insurance co.–and they PAID–for two C-sections in one day! My employer had an administrative-services-only policy, where all the medical costs were passed through directly to the company, so every penny of the overpayment was a dollar for dollar ding to my employer. So of course neither the hospital nor the insurance co. gave a hoot when I called to complain. I finally passed the ridiculous mess on to the HR department, but never found out whether or how it got sorted out. But can you imagine an insurance company employee rubber stamping a charge for two C-sections on the same mother on the same day? If nothing else, you would think he or she would be compelled to send a sympathy card!
I had a year long debacle with a specialty drug pharmacy provider and BCBS-Kansas. It was the 27 circles of hell…each one blaming the other for supposed coding issues. This all occurred after the drug was pre-approved. After 12 months and a total cumulative statement showing I owed $96,000, I wrote a letter to BCBS CEO and sent it certified. Got a phone call 2 hours after it was delivered! I also got assigned some high-level administrative person to “oversee” my account from then on. D was on that drug 13 years…so glad she isn’t now.
D went to urgent care last fall for bronchitis. Charge for visit, “quick” strep test, cultured strep test, cough syrup, inhaler, and antibiotic = $745.
I win. True story. My son was born 31 years ago, my was a premie. He was in the NICU for 110 days or so. For some odd reason…our insurance company was mailing us the checks for his care rather than sending directly to the health care folks. But we got TWO of every check. We started keeping good tabs on the EOBs and what the checks covered…and we sent the duplicates back with Xerox copies of the check we cashed…the duplicate. And we asked that they stop sending us duplicates.
Didn’t help…checks continued to come. We called our lawyer. He advised us to put the duplicate checks into a separate checking account so when it was resolved, we could just cut a check and send it back. That is what we did.
But wait. Blue Cross-Blue Shield assigned an auditor to our account, as they should. We sent them detailed lists and copies of all the checks…dates of service, costs, amount paid,etc. Really, all they needed to do,was proof what we were sending them.
They did three separate audits of the billing and account and could not figure out what was wrong. We had a personal name number we were communicating with.
Anyway…about a week before our kid was discharged, BC/BS sent us a letter saying they were done auditing. They offered that we could keep whatever overage we had (well over $30,000), but they were not paying any additional charges from this hospitalization. Really? Baby was not in the NICU any longer…costs were for a regular hospital bed. So we paid the five or six days of bills from the money in the account.
Our lawyer suggested we not touch the balance (a lot) for one year. Just in case.
After that, we used the money for a down payment on our first house.
I check every bill…every EOB…everything. Every time.
I don’t know about how they coded your son’s procedures but any scratch to an eye can be very serious. I ve done it twice (both times while prunning shrubs) and the first time was on a Saturday night. I called my opthalmologist who insisted I go to the ER immediately and once there I had to wait for the opthalmologist on call. Luckily, it wasn’t a long wait as my dr. insisted I go to the hospital with the trauma center - which on a Saturday night can be a war zone - not the community hospital, because they have Opthamologists on staff. My cornea was scratched and I was given antibiotic eye ointment. I didn’t have any kind of stain done. The second time, since I had the ointment, I didn’t go to the ER and it wasn’t painful like the first time but my opthalmologist insisted I come in immediately the next morning before he went into surgery. Fortunately it wasnt scratched and he didn’t do any kind of stain either.
Did they put the numbing stuff in his eye? Maybe that is coded as an injection.
When my middle child was 9 weeks old, he was hospitalized with RSV for five days. He required oxygen and breathing treatments - that was it. When we got the bill, I saw a $500 charge for "Operating Room." When I inquired, they asked, "Were they THINKING about operating on your son?" Uh, no. Insurance would have paid the charge but I kept pushing and they finally removed the charge.
When my oldest son was 13 or so, he had a hernia operation. Since has a bleeding disorder, they gave him a dose of recombinant factor VIIa, literally THE most expensive medicine around. Each child dose is over $10,000. Then the surgery got delayed because of an emergency in the OR. The factor doesn't last very long, so they gave him another dose. Sure enough, they billed us for both the doses! That took even more work to get removed from the bill, but they finally did.
I have had “operating room” charges on my bill even when I was not operated on when I went to a medical center out of state where my MD practices. Insurer said that is typical to be charged an overhead fee and they had no problems paying it and said it was standard. I guess I prefer to pick my battles. Perhaps that is why the charge at Stanfrd was so high at $19,000+.
Upcoding visits is a very common thing unfortunately.
I am eagerly awaiting my most recent bill to try and determine if it was coded as a 99213 or 99214. My PCP touched my foot, literally and that was it, and prescribed one uncomplicated medicine. If it is a 214 I will be crying livid.
This has happened before with another PCP and was actually the NP who upcoded my visit. I was shocked to see a brief, uncomplicated visit where my history wasn’t explored, no tests were ordered and no medications were prescribed and only one system examined was billed as a 214.
When I requested the notes I saw she documented that she had explored/examined 5 systems (umm, no, you did not do a cardiac, respiratory and abdominal exam!). That is fraudulent billing. When confronted she stated she had “forgotten to change the template on the EMR.” Hmmmm… I call that upcoding and fraudulent. It was a shame too since I liked the PCP himself.
