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10 Things You Should Know About Medical Bills


By now you have probably been the victim of bad medical billing. It could be relatively harmless, damage your credit rating, or, in some instances, send you to bankruptcy court.

By now you have probably been the victim of bad medical billing. It could be relatively harmless, damage your credit rating, or, in some instances, send you to bankruptcy court.

Here are some things you should know about medical bills:

1. They are frequently wrong; particularly for inpatient services

2. There are many reasons why your insurance company refused to pay or you received an erroneous medical bill.

3. Most patients and their doctors have a low insurance IQ

4. To contest a charge or appeal, you need to know who charged you for what service and whether there was appropriate documentation to justify the charge. That means you need to know something about International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes and various levels of evaluation and management codes (E/M). Compliance officers teach doctors that if you didn't document it, you didn't do it and if you didn't do it, you can't bill for it. That said, it does not mean it does not happen.

5. Payers make money by taking in more money than they pay out. Don't be surprised by a system that is opaque, very difficult to navigate, frustrating, and maddening. Pricing is another story.

6. If you are a health professional patient with a billing issue, do not expect professional courtesy or consideration. Consider yourself lucky if you get it.

7. Billing codes and rules are continually changing, so it is likely that even the most well meaning doctor is as frustrated with the system as you are. In addition, your doctor is probably using an electronic medical record that is designed to include information that may or may be relevant to your care or even accurate and that is intended to document a justifiable level of care for billing.

8. Be sure to document, document, and document when appealing a charge, particularly when it comes to Medicare

9. If you get no satisfaction by talking to the doctor, then talk to the doctor's billing person or representative. If you are dealing with an academic medical center, then it is likely that the bills will be processed and sent by a centralized billing service representing clinical faculty. You might receive two bills, one from the facility billing you a "technical component" and another from the doctor for professional services. If possible, shop for doctors that won't charge you a technical fee. Be aware of possible overbilling for services that are not allowable because of inadequate compliance with attending supervision of resident guidelines. Also, most residents, particularly those that have just started their training in July, have no clue how to bill. They are not taught it in medical school. If they check the wrong box or circle the wrong code and it is not corrected, you might be the one who pays the price.

10. Be persistent and educate yourself. Other options are hiring a patient advocate or filing a complaint with your State Board of Medical Examiners (SBME) for egregious behavior. However, in many instances, the SBME will refuse to consider your complaint if it does not have to do with quality of care.

Many of these billing problems are predictable and can be nipped in the bud by informing yourself about potential charges, their amount, and how much you will need to pay out of pocket.

Don't be afraid to ask about the potential cost of care and don't be surprised if your doctor does not know the answers. Sick care cost accounting and billing is a black art.

Don't be a victim. Forearmed is better than forewarned.

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Victor J. Dzau, MD, gives expert advice
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