How to Spot Medical Billing Errors and Appeal Health Insurance Claims

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For family caregivers, dealing with medical bills and insurance claims can seem like a full-time job. Closely inspecting every itemized bill and studying the details of an aging loved one’s health insurance coverage probably aren’t at the top of your to-do list when you’re focused on juggling doctor’s appointments and providing hands-on care. But the truth is that health care providers and insurance companies often make billing errors that can be very costly to seniors and their caregivers.

NerdWallet Health analyzed data from across all Medicare Compliance Reviews of U.S. hospitals conducted by the Office of the Inspector General in 2013 and found that 49 percent of investigated Medicare claims contained medical billing errors. To make matters worse, these mistakes resulted in approximately 26 percent overpayment for the actual care services provided. As health care costs and medical debt soar, it is more important than ever for Americans to be vigilant about maximizing their health insurance coverage and monitoring their bills and claims for costly mistakes.

How to Minimize Health Care Costs

The best way to prevent surprises when it comes to health care costs is to become familiar with all of the details of your insurance coverage. Unfortunately for family caregivers, this means pulling double duty to understand their own health insurance as well as their aging loved one’s coverage, which is often provided by Medicare, Medicaid, the Veterans Health Administration, private insurers or some combination of these.

Trying to make sense of health insurance coverage can be difficult and time-consuming, but it will help you minimize and more accurately anticipate health care costs when your loved one requires medical testing, must establish with a new care provider or is hospitalized. (Becoming well-versed in these matters will help you better manage your own health care costs, too.)

One of the most important things to understand with many types of health insurance is the difference between in-network and out-of-network facilities and individual providers. Most insurance plans contract with a specific network of providers. Some plans offer a certain degree of out-of-network benefits, but patients tend to enjoy the greatest coverage and lowest costs when receiving care services within their network. For example, patients who elect to receive Original Medicare (Parts A and B) must confirm that their providers accept Medicare assignment to ensure their care is covered. However, some patients with Medicare Advantage Plans (Part C), which are managed by private insurance companies, must use in-network physicians in their geographic area or else they may not receive any insurance reimbursement.

When making an appointment with a new provider, always check that they accept your loved one’s insurance. Obtain this information from the practice and then confirm this either by conducting a search on the insurer’s website or by calling their customer service number. Medicare.gov also features a search tool to help consumers find & compare doctors, hospitals & other providers that accept Medicare. This will help you avoid surprise medical bills or balance billing that can leave your loved one on the hook for hundreds or even thousands of dollars.

It’s also vital to understand a plan’s policies for specialist visits. Patients with HMOs (health maintenance organizations) and POS (point of service) plans typically require a referral and/or pre-certification from a primary care doctor for visits to specialists or for specific procedures. Don’t assume that the doctor’s office has handled all of this. Even if the office staff say that they will take care of it, always follow up and call the insurance provider to confirm whether the service will be covered and at what level.

Finally, make sure you have a good grasp of the deductible, out-of-pocket maximum, and co-insurance and copay responsibilities associated with your own health insurance plan and that of your loved one.


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Common Medical Billing Errors to Look For

As if understanding how insurance policies function and anticipating care costs wasn’t already complicated enough, consumers must also be vigilant about spotting billing errors. Improper medical coding is a common cause of unexpectedly high medical bills and denied claims. The wrong codes may pertain to procedures a patient never received or the codes (whether correct or incorrect) may be duplicated. Furthermore, insurance companies may deny claims that do not contain adequate or accurate patient information or diagnostic information.

These mistakes happen all the time, which is why it is important for consumers, especially family caregivers who are advocating for their loved ones, to ensure bills and explanation of benefits (EOB) statements reflect the actual care and services that were provided. Hospital bills can be particularly confusing because of the sheer quantity of tests, services and associated charges that a patient can rack up in just a short time.

Never hesitate to ask for and review an itemized bill after every episode of care. If you see something that doesn’t make sense, try to get it resolved immediately. If you feel you are being charged for services that were never received, then ask for a copy of your loved one’s medical records. The sooner these issues are addressed, the less likely they are to get lost in the fray and pose bigger problems down the road.

7 Tips for Disputing Health Insurance Billing Errors

Even if you are vigilant about making sure you and your loved one use medical facilities and doctors who accept your respective health insurance plans and going over bills with a fine-tooth comb, any mistakes made in the billing and claims process that are outside of your control must still be rectified somehow. The following suggestions will help prepare you in case you ever have to fight an insurance company to cover a claim or discuss payment plans with a medical provider.

  1. Keep detailed written records of every contact you have with the health care provider or insurance company. This includes dates, times, names, what was said, next steps, etc. If you fax something, keep a copy. If you email something, keep a copy. If you mail something, you guessed it, keep a copy.
  2. If a customer service representative makes you a promise, get it in writing. For example, if an employee in the hospital’s billing department says they will adjust or write off a charge, ask for written confirmation, preferably by email. If a claims adjuster says that they will investigate your issue, ask for them to write you a note indicating this, along with a projected timeframe for when you can expect a response.
  3. If your account has wrongly been sent to collections, demand that the health care provider immediately correct this and provide you with a written explanation that you can send to the three credit reporting agencies to mitigate the effects on your credit.
  4. If you don’t understand a charge, ask for an explanation. If the explanation doesn’t make sense to you, then ask to speak to a supervisor. If you believe that a charge is inappropriate (either an error or outright fraud), don’t hesitate to challenge it, preferably in writing. If you believe fraud is involved, report it to your state’s insurance fraud bureau or directly your insurance provider.
  5. If something doesn’t make sense to you on an explanation of benefits statement or a Medicare Summary Notice (MSN), question it right away. Call and ask why a claim was processed the way it was. There are usually grievance or appeal procedures, but these must be done within the specific timeframes stated in the policy documents. You can find detailed information about the appeals process and how to file a complaint on Medicare.gov.
  6. If you are told not to pay a bill while it is being researched or revised, be SURE to get it in writing! If you agree to a payment plan or a partial payment as “payment in full,” get it in writing! Failing to obtain evidence of agreements like these may risk the bill going to collections.
  7. If you don’t have the time or patience to handle your loved one’s medical bills and related insurance matters yourself, there are professionals who are available to assist you. Your local Area Agency on Aging offers free Medicare counseling through the State Health Insurance Assistance Program (SHIP). Medical billing advocates also specialize in rectifying billing errors and can be hired to address a specific problem or to regularly review all of your loved one’s medical bills and claims to ensure everything is correct.

Everyone should review their medical bills and how their claims were processed, even if they believe that they have “good” insurance. Billing mistakes can and do happen, and patients are responsible for monitoring their statements and either fighting to rectify things or paying up. The absolute worst thing you can do is ignore questionable paperwork and large medical bills. If you’re worried that you and your loved one can’t pay what’s owed, you’re always better off trying to negotiate a payment plan or possibly a reduced charge than simply putting it aside to deal with later and ending up damaging your credit.

Sources: NerdWallet Health Study: Medical Debt Crisis Worsening Despite Policy Advances (https://www.nerdwallet.com/blog/health/medical-bills-debt-crisis/)

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