Find and fix mistakes on your medical bills
Ever get a bill from your doctor that you thought should have been covered by insurance? You’re not alone: 7 percent of claims contained errors in 2013, according to the American Medical Association, often leaving consumers with the bill.
And errors may become more common, because insurers and doctors will have to get used to a new coding system for diagnoses next year. Untangling those mistakes is almost always up to you. It’s an often time-consuming and frustrating task. To make it easier, here are five things to watch out for:
1. The wrong code.
If your doctor uses the wrong one, your insurer won’t pay. “Maybe they sent a code missing a digit,” says Pat Palmer, president of Medical Billing Advocates of America, which helps consumers resolve problems. “Or put the code for a pregnancy test on a man’s record.” Ask your insurer whether there was a coding mistake. If so, ask your doctor to resubmit the bill.
2. A typo.
A misspelled name, old insurance information, or a wrong policy number will cause an insurance company to kick out a claim. The insurer can help you find and correct the error, and reprocess the claim.
3. A claim denial.
Health plans might deny a claim if other coverage is more appropriate. Workers compensation might cover carpal tunnel syndrome, a common workplace injury, for example; auto insurance might cover an injury related to a crash. You need to submit your claim to the right place or convince your health insurer otherwise.
4. Prior authorization.
If your plan requires prior authorization for certain tests or procedures, a referral to see specialists, or certification from your insurer before elective surgery, and you don’t get it, your claim won’t be paid. Your plan documents spell out the rules. There’s no recourse for that type of denial.
5. No discount.
Insurers rarely pay the amount that a doctor’s office bills; they almost always negotiate reduced rates. But sometimes doctors try to collect the difference. To check, look at the explanation of benefits form your insurer sends after every visit, and compare the amount billed with the member rate. If you get a bill for the difference, send your doctor a copy of your EOB.
More complicated is when your insurer fails to calculate the discount. That’s a problem especially when you haven’t met your deductible and have to pay in full. You can spot the problem because no discount will be listed on the EOB. In that case, call your insurer and get the form corrected.
5 tips for dealing with errors
1. Know what your insurer covers. Every non-Medicare plan comes with a summary of benefits and coverage, which describes what’s covered and what’s not. If you don’t have it, get it from your insurer— and read it. Find Medicare plan details at medicare.gov.
2. Keep all bills and EOBs. Don’t pay a bill until you receive the explanation of benefits form from your insurer and compare it with your doctor’s bill.
3. Call the insurance company first. If you see a problem, start with the insurer’s customer-service line.
4. Ask for your doctor’s billing office. If your insurer says you need to follow up with your doctor, ask for the person who handles billing. He or she is paid to untangle problems like yours.
5. Take good notes. Include dates, times, names, and a summary of all conversations you have.
This article also appeared in the June 2014 issue of Consumer Reports on Health.
Consumer Reports has no relationship with any advertisers or sponsors on this website. Copyright © 2006-2014 Consumers Union of U.S.