$3100 bill for "completely covered" procedure.
December 19, 2013 3:12 PM   Subscribe

My doctor sent me for a colonoscopy due to family history. The clinic gave me some paperwork saying it would be completely covered unless they found something, and then it would be $250. They didn't find anything. I lost the paperwork. Now they're sending me bills for $3100.

I had the procedure done on September 26. I've gotten a number of bills since then.

I've called the insurance company a number of times. They've told me on two different occasions that the doctor's office coded the claim wrong and that it should have been covered--and will be covered, if they resubmit the claim with the correct code. The doctor's office coded the procedure as "diagnostic"; I'm 38, diagnostic colonoscopies aren't covered till 50--but my father died of colon cancer which had metastasized to the point it was inoperable by the time they found it when he was 43, so according to the insurance company it should have been coded as family history/high risk.

After each of my calls to the insurance company, they called the doctor's office to advise them to resubmit the claim with the correct code. And then each time I got a phone call within two days, from the clinic, attempting to get me to pay this $3100 bill I had no reason to expect. The clinic says they can't change the claim; the doctor has to do it.

I've also called the doctor's office directly, doubting it would do any good when a call from the insurance company didn't, and indeed it didn't. Meanwhile I keep getting bills and annoying phone calls.

Our workplace has an insurance advocate. Today the insurance advocate told me the same thing the insurance company did: the doctor's office needs to solve the problem. The doctor's office is not solving the problem.

At this point it feels like they've done a bait and switch, or maybe they're just leaning on me to give them a $3,100 interest-free loan until they can sort out whatever problem they're having in the office.

What is the next step here? Please assume I have, on a scale of 1 to 3,100, zero intention of paying this bill and every intention of getting them to correct their mistake.
posted by johnofjack to Health & Fitness (26 answers total) 2 users marked this as a favorite
Response by poster: I should add that at every step along the way, when someone asked them why I was having a colonoscopy, I told them about my father's colon cancer. The anesthetist coded the claim correctly. The hospital and the doctor who performed the procedure did not.
posted by johnofjack at 3:13 PM on December 19, 2013

I would go to the doctor's office in person and insist that they sort this out, with copies of all relevant documentation, and I would not leave until it was done or I was arrested for having a huge tantrum.
posted by elizardbits at 3:21 PM on December 19, 2013 [17 favorites]

Is the practice part of a larger group/hospital? If so, call around there (patient services, division/department chief, practice administrator).
posted by ThePinkSuperhero at 3:21 PM on December 19, 2013 [1 favorite]

Call the doctor's office in the morning, ask them about the situation. Ask the doctor to call you back, if he doesn't call you back by mid-afternoon, call again. Call again the next morning, explain the situation, ask how it can be fixed, ask the doctor to call you back, call again in the afternoon. Keep calling until they resubmit the claim correctly. Be unfailingly polite, but insistent. If you can, go into the doctor's office with your paperwork, and stand there until they fix it.

The clinic doesn't give a crap about the error; they can't fix it, and as far as they're concerned, you're supposed to pay them, and they want their $3100. The doctor's office probably doesn't care either -- they're likely already paid -- but they can fix it, and you need to give them a reason to care. Being a thorn in their side until they fix it might solve the problem.
posted by brainmouse at 3:22 PM on December 19, 2013 [5 favorites]

Honestly, I would physically go to the office of the person responsible for coding it and speak to them in person. There are words I would use that might be meaningless in the long term but might light a fire under their asses. Words like "intentional infliction of emotional distress". This might not be in your wheelhouse, but from time to time I've had problems in this kind of arena fixed by crying.

But I think that showing your face and personalizing the problem might solve it.
posted by janey47 at 3:23 PM on December 19, 2013

Do not go in person. This is a matter that can be handled without that; you just have to figure out who. Sorry you're getting the run around.
posted by ThePinkSuperhero at 3:23 PM on December 19, 2013

The doctor's office can absolutely resubmit a claim with modified codes - heck, I configure our IT systems to do this on a daily basis.

What did your insurance advocate say when you mentioned that the doctor's office is submitting the wrong code and refusing to budge? This isn't something that is normally handled by the patient and eventually you will end up as bad debt in their books and passed on to collections. Something is off as everyone is losing here.
posted by lpcxa0 at 3:24 PM on December 19, 2013 [2 favorites]

Rather than calling the hospital and Doctors' office, I would go visit them and speak to someone in person and armed with documentation from your insurance company regarding the incorrectly coded claim.

Refuse to leave the Doctor's office until it is handled to your satisfaction and once you have copies showing the correctly coded claim. If need be, do a conference call while at the Doctor's office with the hospital and insurance company.
posted by stubbehtail at 3:24 PM on December 19, 2013 [1 favorite]

Who have you talked to at the doctor's office? Call them back, noting that you have already asked them (and how many times you have asked them) to resubmit this and they have not. Confirm whether they are willing to do it and just haven't or if they are unwilling to do it. If they are willing, ask them when you can expect it to be resubmitted. Tell them you need them to tell you as soon as they have resubmitted it.

If anyone gives you push back at the doctor's office, ask to speak to their supervisor. Is this your regular GP? Try to speak directly to them.
posted by soelo at 3:28 PM on December 19, 2013

i would go to the doctor's office and ask them why they're ignoring you and the insurance company. and also switch doctors after this. my doctor googles claim codes whenever i need a test or a procedure to make sure it's being coded in the most beneficial to me way possible while also being ethical.
posted by nadawi at 3:29 PM on December 19, 2013 [1 favorite]

Call the doctor's office in the morning, ask them about the situation. Ask the doctor to call you back, if he doesn't call you back by mid-afternoon, call again. Call again the next morning, explain the situation, ask how it can be fixed, ask the doctor to call you back, call again in the afternoon. Keep calling until they resubmit the claim correctly. Be unfailingly polite, but insistent. If you can, go into the doctor's office with your paperwork, and stand there until they fix it.

This is exactly what I would do except I wouldn't go there. Just really step up the "I need to get this handled and I will be happy to get out of your hair once this is handled but NOT BEFORE" Wait them out. This is their issue. Be polite but not relenting. You are the ocean, they are the rock on the shore. You will eventually wear them down.

Sometimes you can get people from the insurance company to do a 3-way call between you and your doctor's office if you are not able to get your doctor's attention in some other way. You also might try this with the insurance company and the clinic. What does the doctor's office say when you speak with them?
posted by jessamyn at 3:37 PM on December 19, 2013 [2 favorites]

Best answer: Have you mailed a letter yet? I might try that, could get your info into the right hands. Mail it to the address on the billing statement and the doctor's physical practice location.
posted by ThePinkSuperhero at 3:39 PM on December 19, 2013

Response by poster: I have not yet been able to speak to the doctor directly; it's always been office staff leaving messages (which, it occurs to me, I have no proof he even got).

The doctor who is not resubmitting the claim is not my GP. I love my usual doctor. I have no intention of seeing this other doctor ever again, even if my usual doctor decides this needs to be--blech--an annual or biannual thing.
posted by johnofjack at 3:41 PM on December 19, 2013

Best answer: You MUST deal with this in writing. "What someone told you on the phone" is worth exactly nothing; the people who do this on the phone are only kicking the can down the road so that any rights you may have will expire. None of them want to help you, and none of them want to pay the bill. They only want it to become a bill that you can no longer dispute, and must pay.

If you write a letter (and you should, stating what's happened so far and what you want to happen next) and somebody calls you, get the person's name, take notes of what the person says, and then ask the person to confirm in writing. (They won't do so, but you should ask.) Then YOU should write a follow-up letter stating what the person said, that you asked for written confirmation and will be expecting it, and then stating what you want to happen next. Lather, rinse repeat.

Good luck.

posted by spacewrench at 4:05 PM on December 19, 2013 [1 favorite]

Agree with Spacewrench. As much as possible, do all communication by email. However, I would advise not saying anything about how you have absolutely no intent to pay in an email. You can say that on the phone, if you must.
posted by MeanwhileBackAtTheRanch at 4:17 PM on December 19, 2013

Best answer: This happened to my father as well and I had to make dozens of calls to the billing hospital, insurance company and doctor's office. I documented everything--names, dates, time and conversation. It took several months to get it corrected but it is possible with persistence.

I was given some great advice from the insurance company rep I spoke to who told me to call the billing hospital to let them know there was a coding error I was trying to get resolved and to temporarily suspend collection activity. I explained the situation to the billing person who made notes on the account. I'd give that a try while you get this sorted out.

Good luck, keep at it..
posted by loquat at 4:32 PM on December 19, 2013 [2 favorites]

When you say they didn't find anything, do you mean they didn't find any findings at all, or just that they didn't find anything of concern/any pre-cancerous polyps? Because it's a remarkably shitty feature of some insurance programs that a relatively common, trivial "diagnosis" like hemorrhoids or diverticulosis may be considered a "diagnosis", and therefore may cause this to be coded as diagnostic.

So while you're doing everything suggested above, I'd also suggest making sure there were no findings of any kind. The doctor's office may be submitting something like diverticulosis as a diagnosis.

Good luck. It sucks.
posted by pie ninja at 4:33 PM on December 19, 2013

Best answer: I work in medical billing (though not in-patient). Do you have your EOB (explanation of benefits)? If not, call your insurance and ask for a copy.

Call the clinic. Ask the rep if they can see any logs in reference to your previous calls. Either way, re-explain the situation. Ask them to note everything on your account. Get them to note the claim was submitted incorrectly. Ask for a reference number for your conversation. It's perfectly okay to tell them you won't pay it- you are not responsible for incorrectly billed claims. Say that; you want the clinic to bug the doctor too. Ask them to suspend collection activity, as the incorrectly coded claim must be corrected.

Write the doctor's office a letter. (If you can, try to find out who does the doctor's billing.) Explain the whole situation again. Include a copy of the EOB highlighting that they used the wrong code. Send it by certified mail; CC the clinic. The second time, CC your state's medical board too. Repeat. While doing this, call the doctor's office every time you can. They won't do reference numbers, but you can do names and time of call. In every letter you send to the doctor, include all the calls you have made regarding this.

The only thing that fixes this is persistence. Going there is person will be of little use. Document, document, document.
posted by spaltavian at 5:27 PM on December 19, 2013 [9 favorites]

Hi. This has actually happened to me.

The piece of paper they handed you doesn't matter. The issue is getting in to the doctor to get him to re-code it.

The person who does the coding is not actually the doctor. It's the doctor's billing department. That's who you need to speak to. And, straight up, the billing department ALWAYS gets this one wrong.

If they will not transfer you to the billing department on the phone, then you will need to go in. Be polite, but firm, and let them know you won't leave until you can meet with someone. Go in that morning and be prepared to wait all day. (If they're being resistant and you tell them you're planning to come in, then they will likely transfer you.)

I have also found that calling frequently - sometimes twice a day - helps.

Are they a part of a medical group? Is there a larger organization that the medical group is part of? It can pay to go up the food chain; this has been helpful to me in the past when I wasn't getting enough of a reaction. Many medical groups are for-profit organizations and when I've emailed vice presidents I've gotten surprising action on billing.

If that fails, then make an office appointment with the doctor and explain the situation.

Have you been keeping a written log of every time you called, who you talked to, and what was said? If not, I suggest that you start. It is very important that you have a log of when you called (date and time), who you talked to, and what was said.

Pie Ninja is correct - there is a difference between "no findings of any kind" and submitting something like "diverticulitis" - however in my experience even this will not stop the billing department from changing the coding.
posted by rednikki at 5:28 PM on December 19, 2013

I once had a similar issue and I did all the above about documenting and calling. The additional thing I did was made an appointment with the Doctor's office manager. I took everything in and sat with her while they solved the problem. Try to schedule the appointment with her/him during the Doctor's actual office hours so they can submit the change right then and there.
posted by cairnoflore at 5:51 PM on December 19, 2013

Seconding cairnoflore, I have had good luck with asking to speak to the office manager. It's really part of their job to resolve these sorts of issues.

If all else fails, I also had a bill similar to this turned over to collections and when I explained it to the collections person, they were able to get the office to resubmit it. Hopefully it won't go that far, but there's that.

Good luck. Patience and persistence will win the day.
posted by SweetTeaAndABiscuit at 6:52 PM on December 19, 2013

Response by poster: I called Shands yesterday and was bounced around to a couple of different departments, ending up with UF Patient Relations, speaking to a young woman who would give only her first name and who stated that they don't keep reference numbers in regards to phone calls. (To quote Neil Gaiman: "Raises eyebrow. Thinks. Raises other eyebrow.")

She claims to have suspended collections while the billing error can be sorted out, also claims it can take up to 30 days.

I've just finished typing a letter summarizing what's happened so far, stating that the bill is in error and the claim needs corrected so that the insurance company will pay it, and offering any documentation that might help expedite the matter. I've read it over; it seems polite and strictly factual. Off to send it--
posted by johnofjack at 6:27 AM on December 21, 2013 [1 favorite]

Response by poster: Of the three letters sent by certified mail, at the same time, one arrived the morning of 12/24/13, one arrived the afternoon of 12/27/13, and one still hasn't arrived.

The place that didn't get the letter just sent me another bill, this one threatening collections. I emailed them a brief summary of the situation, attached the letter I'd sent via certified mail, and urged them to correct their error so they could be paid.
posted by johnofjack at 2:55 PM on January 3, 2014 [1 favorite]

Response by poster: They finally wrote me back and said they looked it over and decided to credit the account. I double-checked with my insurance company and they've put both the claims through a second time, this time with the correct code.

Four months to sort this out is ridiculous, but I'm glad it didn't drag out as long as it did for two of my coworkers. One of them told me she was arguing with them for a year before the claim was corrected. I thought that was ridiculous; then someone in the department I used to work in told me that her claim took just under two years to get corrected. Amazing.
posted by johnofjack at 2:00 PM on February 9, 2014

Response by poster: ... and I just got another bill from that stupid goddam doctor.
posted by johnofjack at 2:32 PM on April 25, 2014

Response by poster: Left work early today to go in with all the documentation I have, including the letter from Shands from Feb. stating that they'd looked over the case and refiled the claim with the correct code.

I made the point more than once that Shands got this sorted out, and was paid, two and a half months ago.

According to the people at the office that sent the bill (and I really shouldn't call the doctor stupid; he probably had nothing at all to do with this mess after the very beginning of it), they'd refiled the claim on January 7 but then it got the "family history" code added to the other one rather than replacing it. The person I talked to seemed a bit baffled, and said she was sending it to her supervisor so she could "light a fire" under someone.

Nothing to do but keep checking up on it, I guess, and being polite-if-a-bit-exasperated, and completely unyielding that this is not my debt (because it isn't).
posted by johnofjack at 5:03 PM on April 28, 2014

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