Trying to fix a medical billing error: At what point do I give up?
March 20, 2014 10:57 AM   Subscribe

I got a small bill for lab work done as part of a routine annual exam. The entire amount should have been covered in full. At what point do I give up and just pay the bill?

I have a high deductible health plan with associated HSA funded via pre-tax payroll deductions. My deductible has been met for 2014 and I'm now in the coinsurance period.

I received a small bill ($8.25) for lab work done as part of a routine annual exam at an in-network doctor. It's my understanding that routine exams and physicals are covered by my health plan at 100%, regardless of whether or not the deductible has been met. I understand this is also a new requirement of insurance plans under the Affordable Care Act.

$8.25 is not going to break my bank by any means. However, I pay for my health insurance, and so does my employer, so in principle, I'd like to have any and all covered expenses, well, covered.

I called my insurance company this morning. They looked over the claim. They said yes, all the lab work is 100% covered as part of a routine exam. However, the doctor's office used "an inappropriate billing code" for some of the tests. The customer service rep went on to explain that there were billing code changes resulting from the Affordable Care Act that "your doctor might not be aware of." They only covered the charges billed under the correct ICD-9 code, and gave me a list of ICD-9 codes that should have been used for the other tests. (Googling these codes and what they mean, it makes perfect sense.) I was told to call the doctor's office and have them resubmit the claim with the additional codes.

I called the doctor's office. I was bounced between them, their billing office, the lab's billing office, and finally back to the doctor's office. Per their request, I faxed over a copy of the bill I received and gave them the list of ICD-9 codes that my insurance company gave me.

I just got a voicemail stating that they're not going to change the billing codes because everything is correct "as far as I and my manager are concerned."

At this point, looking at my current salary, I've spent far more than $8.25 worth of my time fighting this bill. Should I give up on this and just pay the bill from my HSA?

My principles on this say I'm not getting what I'm paying for (insurance coverage). However, if I hadn't hit my deductible for this year, this bill would have been around $55. I haven't spent that much of my time on it yet, but I have certainly exceeded $8.25 worth of my time, and part of me says I should just give up and pay it.

No, I'm not going to give out the diagnostic codes, either the ones used or the ones given to me by insurance, because anyone can Google what they mean and (in my opinion) that would violate medical privacy.
posted by tckma to Health & Fitness (13 answers total) 1 user marked this as a favorite
Best answer: I'd pay it and move on.

This is not a hill I want to die on. It's your doctor's office's mistake, and if you want, you can send a letter to them explaining it. But, it's a small amount.

Next time you see your doc, ask for some office samples of something, to cover the mistake.
posted by Ruthless Bunny at 11:03 AM on March 20, 2014 [3 favorites]

At this point, looking at my current salary, I've spent far more than $8.25 worth of my time fighting this bill. Should I give up on this and just pay the bill from my HSA?

That's exactly what I would do. Pay and move on. I've fought small bills like this on principal before and regretted it.
posted by craven_morhead at 11:04 AM on March 20, 2014

Best answer: If they used an ICD-9 code for a specific diagnosis, then your insurance is less likely to cover it as part of a routine exam. For example, the ICD-9 codes used for a routine exam would usually not violate your medical privacy, as opposed to those used for some diagnosis. So if this is really routine, the fault lies with your physician's office.

For whatever reason, your physician's office refuses to help you here. The most generous interpretation is that the tests are not really routine, they ordered them for you because of a specific indication, and they wouldn't have ordered one for everyone coming in for a physical. The least generous interpretation is that they might get paid a lower reimbursement rate for procedures when they lack a diagnosis. Or they just don't want to deal with the hassle.

Personally I would start looking for a new physician whose office would be more willing to help you navigate the insurance system. You could tell your doctor that you'll do this and maybe this will change their mind.
posted by grouse at 11:09 AM on March 20, 2014 [3 favorites]

Agreed, pay it and move on. Including moving on to another doctor.
posted by Grither at 11:12 AM on March 20, 2014 [2 favorites]

I would wager it cost you more than 8.25 to ask this question. This is noise. Pay it and forget it.
posted by three blind mice at 11:23 AM on March 20, 2014 [1 favorite]

Response by poster: For the sake of argument, let's say there were three lab tests.

All three tests were billed under code A, which Googles to "routine annual exam."

The insurance company paid in full for test #1 billed under code A.

They said tests 2 and 3 should have been billed under code B, which Googles to "routine physical exam" (note the very subtle language difference), or code C, which Googles to "routine blood test for Some Specific Condition." <-- here's the medical privacy issue.

The doctor's office isn't even the one getting paid here. This is a bill from an in-network outside lab (one of the national lab chains) to which they sent test samples. So I don't think it's a case of "we're gonna get paid more for this if we bill under Code A versus Code B or Code C," since the lab is the one getting paid.

Thanks. I'm just going to pay it. We like this doctor, after having seen at least three over the last few years whom we didn't like. I'll deal with the screw-ups of their administrative staff. I've learned that administrative staff in doctors' offices are universally terrible regardless of the quality of the doctor who employs them.
posted by tckma at 11:32 AM on March 20, 2014 [1 favorite]

Best answer: And next time anyone goes in for care, bring it up! "Last time there was a coding error and I got billed for XYZ. The insurance company confirmed that if it had been coded differently, I wouldn't be charged. I tried talking to your office staff, but I gave up and paid the bill. Can you check on that this time?"
posted by vitabellosi at 11:40 AM on March 20, 2014 [3 favorites]

Best answer: I would dispute this.
I would get mad about it.
Later on, I would regret the amount of time I wasted on it.

posted by RedOrGreen at 12:07 PM on March 20, 2014 [3 favorites]

Best answer: So, one thing that could be happening is that your doctor orders some things routinely as part of the "general exam" that are not universally recommended as part of a well-person exam. A classic example is thyroid tests for young healthy women.

A lot of physicians routinely order an annual TSH in young women even if they're not complaining of any symptoms of hypothyroidism, because, well, mild hypothyroidism is not uncommon, it's not an expensive test, they had this patient once who felt terrible for months before she finally got her thyroid checked, etc.

The issue is that if you actually look at the literature, routine TSH screening of asymptomatic people has never really been shown to have any benefit on a population basis, so none of the guidelines support it as part of preventive care the way they do for other tests, like a cholesterol test. As a result some insurance companies will not cover it if it's billed to a preventive services billing code.

The issue you may be having is that the physician doesn't have any other code to bill the test under, if you weren't complaining of symptoms that would be reasonably worked up with the test in question. To use the thyroid example again, it would have been totally reasonable to send the test if you had been complaining of, for instance, fatigue or menstrual irregularities (or a number of other symptoms). If you weren't, and he used a code suggesting that you were, in order to get the test paid for, that would be fraud. So he may not feel that he has the documentation in his records to justify a more symptom-based billing code.

Alternatively there may have been lots of justification and he just didn't check off the right diagnosis code. It's actually kind of a pain in the neck and time-consuming to order a bunch of labs and then painstakingly match them all up to the right diagnosis code.

Or maybe your doctor's admin office is just terrible. That is, unfortunately, another possibility. I agree that you should mention it next time.
posted by The Elusive Architeuthis at 12:10 PM on March 20, 2014

Best answer: Not worth it. But I just wanted to point out the insurance company "blaming" the Affordable Care Act, which seems to be the new go-to line for all these asshole insurance companies.
posted by kuanes at 12:43 PM on March 20, 2014 [4 favorites]

I recently disputed a small charge all the way through appeal (twice) and complaints to the insurance commissioner. It was a waste of time, but I eventually did get all the money I was owed. (FWIW, I paid the charges to the hospital, so it was strictly a dispute between me and the insurance company. They eventually paid the hospital at their cheaper rate, but I forced them to pay me instead the full amount of what I'd had to pay. They're not entitled to their cheap negotiated rate when I've had to pay the bill due to their clear failure to comply with the insurance contract.)

It's not worth it except on principle, but you should definitely submit a complaint to the insurance commissioner. (And, for the $8.25, you can certainly cost them hundreds or thousands in processing, which serves them right for trying to grind you on a bill that they think you won't bother to dispute.)

Fuck insurance companies.
posted by spacewrench at 1:27 PM on March 20, 2014

This happened to me. I had a physical and the Dr ordered blood work and an extra lipid (cholesterol or something) test that isn't normally part of a standard physical. But because I have a history of high triglysorides he orders the test. The insurance company considers this an add-on. I argued it was part of my free annual physical, they argued it wasn't and explained it thusly...If you had an existing heart or liver problem and the Dr needed to check something because of it that would be outside the description of a regular physical. Even though it has now become part of my annual physical.
posted by Gungho at 1:42 PM on March 20, 2014

Pay it, complain to the state insurance commissioner, and send everyone concerned a bill for your time, which will at least make you feel a bit better about the clusterfuck that is medical billing.
posted by holgate at 3:45 PM on March 20, 2014 [2 favorites]

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