How can I avoid a medical billing nightmare next time?
January 10, 2020 7:17 AM   Subscribe

I had a very minor scope and biopsy. Extremely common. Insurance covered it. Now I am getting an avalanche of bills in the mail, from small to large. I think it's over a dozen separate bills at this point. What the hell happened, and how can I avoid this in the future?

I was under the impression that when an insurance policy said that outpatient procedures were covered after a $150 copay, that was the end of the transaction on my part. I guess I was super wrong, because everyone from the anesthetist to the hospital to the equipment supplier to the lab where they sent the sample are hitting me up for more money. That $150 copay has turned into ~$1500 at this point.

I thought that the point of medical insurance was to cover medical expenses, but I guess they can ask for more after my insurer pays them the agreed upon amount? Can someone familiar with the insurance industry tell me what the heck happened and how to avoid getting billed after the fact in the future?
posted by FakeFreyja to Health & Fitness (17 answers total) 8 users marked this as a favorite
 
You should ring your insurance company with the stack of bills in front of you and ask, as this will vary by policy. They may in fact tell you some or all of those bills are covered and pay them.
posted by DarlingBri at 7:24 AM on January 10 [9 favorites]


I guess I was super wrong,

Alternately, someone else was wrong.

If the medical office submitted the claim in a way that didn't quite line up with what the insurance company was expecting, chaos can ensue. I've had issues were there was a dispute/misunderstanding about which one of the many billing codes for a particular procedure is supposed to trigger what kind of coverage. Someone who works in healthcare can probably give better examples.

Anyhoo, don't start paying those bills yet. Talk to the doctor's office where you had the procedure, and talk to your insurance company.
posted by desuetude at 7:43 AM on January 10 [10 favorites]


I am guessing that the $150 copay for outpatient procedures refers to the cost-sharing your insurance imposes on just the bill that the physician generates. Unfortunately, for stuff that is more complicated than just a bog-standard sick visit, more entities/providers start to be involved in your care, and every single one of them generates a separate bill that your insurer will apply different cost-sharing rules to.

Usually the biggest one is the facility separately billing for the use of its procedure room/supplies. When my kiddo got his tonsils out (an outpatient procedure with anesthesia at the local children's hospital), the bill from the pediatric ENT surgeon was a few hundred dollars, plus another few hundred for the anesthesiologist (separate doctor, separate bill), but the hospital charged like $2K as a separate facility fee. (Same story both times I had a baby - the doctor bills were expensive but the hospital cost was roughly ten times as large.) Might that be a part of what is going on?

I'm sorry, it's frustrating. Often times the different providers involved in this stuff don't have explicit business relationships with each other, and no insight into what the other ones are billing, so no one gives patients a real estimate of total costs. In terms of avoiding this in the future: it's probably useful to know that the facility/hospital almost always represents the biggest cost for any sort of procedures, and to either look for a doctor that isn't owned/affiliated with a hospital (e.g., one that does simple things like biopsies in their non-hospital-owned offices) or to be diligent about asking both the doctor performing the procedure and the hospital or facility where the procedure is performed to give you an estimate of costs.
posted by iminurmefi at 8:02 AM on January 10 [3 favorites]


I am guessing that the $150 copay for outpatient procedures refers to the cost-sharing your insurance imposes on just the bill that the physician generates. Unfortunately, for stuff that is more complicated than just a bog-standard sick visit, more entities/providers start to be involved in your care, and every single one of them generates a separate bill that your insurer will apply different cost-sharing rules to.

This - unfortunately, this is the inefficiency in our fee-for-service system. Providers/facilities charge for services rendered, and bill patients for the balance not covered by their insurance. You will probably not be able to avoid receiving bills, but you might be able to speak to the office coordinating your care to get a sense of what sort of balances you will owe. I say "might" because in a fragmented system, it's highly possible the doctor won't know what the lab or the facility or the anesthesiologist will charge, and there might not be a central source that can tell you other than your insurance company after all of the bills have already been submitted.
posted by ThePinkSuperhero at 8:12 AM on January 10 [1 favorite]


Don't assume that you're wrong! Have you received an Explanation of Benefits from your insurance company yet? These can take a few weeks to show up after your treatment/services/whatever, but sometimes they're available online before you get them in the mail, if you have an online account with your insurer.

Some insurers won't automatically send an EOB if you've already used your deductible but if you call and request one they should be able to provide it. The EOB will explain what your insurance company covered and what they think you owe the various parties involved, and why. The EOB may or may not agree with what the various providers are billing you for. It will give you a starting place for figuring out what happened and who you might need to argue with about it.

Definitely don't pay the bills until you are confident you actually owe the money.
posted by mskyle at 8:19 AM on January 10 [12 favorites]


Definitely get your EOB for each of the charges, match them up to the bill, and make sure a) they have been properly submitted to and reviewed by your insurance and b) you actually owe what they say.

For next time, you can get a pre-determination or pre-qualification from insurance which is basically the doctor's office pre-submitting the expected claims (which should include all aspects of care).
posted by DoubleLune at 8:28 AM on January 10 [3 favorites]


I guess they can ask for more after my insurer pays them the agreed upon amount

This is called "balance billing," if that search term helps. Some journalists have been writing about it, and some states have been moving to ban it. (My facts are very vague, but I'd look it up.)
posted by slidell at 8:47 AM on January 10 [1 favorite]


I would start by calling every entity that has billed you. They may not have your insurance information, and thus could not submit bills to them. This may not solve all of your billing problems, but it might solve some of them.

I experienced this after cityboy's hand surgery - and two subsequent surgeries to remove internal rods. The surgeon's bills were not the problem, it was the other practices that didn't have his info who billed as though he didn't have coverage. We received bills from different anesthesia practices for the different surgeries, as well as brace companies. When we provided them with the insurance info we ended up having to pay very little.
posted by citygirl at 8:53 AM on January 10 [3 favorites]


I was under the impression that when an insurance policy said that outpatient procedures were covered after a $150 copay

The copay is just the fee you pay for walking in the door. After that, you have to meet your deductible, which is a much larger amount (several thousands). That's probably what you are paying now. Those costs are reduced to what the provider has agreed to accept for being an in-network provider, but a big chunk nonetheless.
posted by Thorzdad at 9:09 AM on January 10 [1 favorite]


what the heck happened

Network bullshit. Just because the hospital is in network doesn't mean all the people working in that hospital on you were in-network, because fuck you. When biscotti had her gall bladder out, the hospital was in-network and most of the associated staff were too, which is itself a minor miracle, and the surgeon's *firm* was, but somehow the surgeon himself wasn't, so we got a bill for $shitloads.

The better news is that some of this stuff will very probably be covered by your insurance to one degree or another. After the surgery, I talked to the insurance company and they were going to cut us a check for $much_less as reimbursement for surgeon's fee. The surgeon's office then said that they'd be happy to accept $much_less as payment in full for $shitloads, so I just signed the check over to them.

Repeat for every bill you've gotten, because fuck you and because of course your time isn't of any value.

how to avoid getting billed after the fact in the future?

You can't. This is America. Expect shit like this every time you do anything more involved than an office visit. This is the American medical system operating as intended.
posted by GCU Sweet and Full of Grace at 10:17 AM on January 10 [3 favorites]


People are making a lot of guesses here - it could be balance billing, it could be your deductible, it could be something to do with an out-of-network provider, it could be a mistake on the part of your insurer or one or more of the providers billing you, or who knows what else. Get the EOB and go from there. If you can't get an answer that makes sense, and you get your insurance through your employer or union or something, ask someone in HR or your union for help.
posted by mskyle at 10:23 AM on January 10 [3 favorites]


Nthing the advice to get on the phone, wade through phone automation hell, and try to find someone at your insurer who can explain.

I once got sent an itemized list of charges for a regular check-up that added up to thousands of dollars. When I called both the medical practice and my insurance company (sweating and anxious!) the answer was that one of them had sent me a copy of the bill, not because I had to pay it (I didn’t), but because they were going through a contract dispute with each other and, I guess, trying to get the customers involved to make each other look bad, or something. I still don’t quite understand it but I didn’t have to pay a dime of it.
posted by sallybrown at 11:00 AM on January 10


I had this happen recently, and I knew it was covered. What I did was to check the change of insurance box, fill my "new" (that is to say, not new at all) insurance information on all the bills, and just kept sending them back over and over until they stopped. Next EOB I got showed it as covered. Good luck!
posted by the liquid oxygen at 11:08 AM on January 10 [4 favorites]


The copay is just the fee you pay for walking in the door. After that, you have to meet your deductible, which is a much larger amount (several thousands).

Hi, former insurance CSR here. This is not quite correct and could vary depending on the details of your plan. Many plans have either a deductible or a co-pay depending on the service. A more common arrangement is a deductible--let's say it's $4000--and once you've paid the first $4000, you're responsible for co-insurance, i.e. a percentage of the cost of the bill--until you've met your out-of-pocket maximum. So if the surgery cost $15,000, you have a $4000 deductible and a $10,000 out of pocket maximum, you'd have to pay the full $4000 as well as whatever your coinsurance percentage is. Frequently it's something like 20%. So in this hypothetical example you'd owe $6,200.

The best advice I can offer is to echo the suggestion to call your insurance and make them go over each individual charge with you. Claims processing errors and billing errors are maddeningly frequent.
posted by zeusianfog at 11:25 AM on January 10 [1 favorite]


generally there is a copay, and a deductible, and then coinsurance, and an out of pocket max. you might be getting billed the coinsurance amount. or, they might be engaging in balance billing, which is billing you for whatever insurance didn't cover (e.g., insurance covers $100 for a test, but they bill $150 for the test, you get billed $50). this is america. this is how it works. (it shouldn't be this way, but this is what we get)
posted by misanthropicsarah at 11:27 AM on January 10


We have had big bills, which a rep at the insurance company suggested would be covered if the doctor re-submitted using a slightly different billing code.

They know what it should be, and they will pay it if it comes in billed that way, but they won't do anything until the doctor's office says "Captain, may I?" with juuuuust the right lilt.

I makes me grind my teeth SO HARD.

So yeah, call the insurance company and just ask them to help you understand the bills.
posted by wenestvedt at 1:24 PM on January 10


Some errors need correcting.

> The copay is just the fee you pay for walking in the door. After that, you have to meet your deductible, which is a much larger amount (several thousands).

No. The deductible is the first $x that you have to pay before the insurer has to pay. For some policies (ACA policies for the most part) it is often thousands but for better policies it may be $500 - $1,000 per year per person.

Then the copay is your share of the next $y that is approved as a charge. If there is a $500 deductible and a $1,500 bill with a 20% copay, you pay the first $500 plus another $200 copay. The company pays $800.

For nearly all insurers, there is a schedule of approved payments, so an original $2,200 billing might be reduced to $1,500 before all of the above is done. Under many contracts, the provider has to accept that reduction and cannot bill you for the difference. If the contract does not include that prohibition, you may be billed for the $700 difference as well. But it is likely negotiable.

All of this assumes that everything was done in-plan.
posted by megatherium at 10:22 AM on January 11


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