How does HIPAA prevent my insurer from explaining a bill?
July 23, 2020 5:59 PM   Subscribe

I’ve been on the phone with my insurer and healthcare provider today trying to get to the bottom of a murky bill for a medical procedure and hit a wall when the last insurance customer service rep I spoke to claimed she couldn’t discuss what was billed because of HIPAA.

She can see the information, but told me she can't discuss it with me. I told her if I authorized her to discuss it with me that I’m not sure what in HIPAA prevents her from helping me understand the bill, but she insisted I would have to talk to my doctor. This seems incorrect?

The billing department for the doctor told me I would need to talk to my insurer, and I’ve already talked to them both several times today. So I give up for today! I am asking this question now mainly out of curiosity about how HIPAA could prevent an insurer who can see the information I need from discussing it with me, the patient.

If you’re curious what my billing question was about: I received a large bill for an echocardiogram and checked my claims on my insurance website to see the breakdown. I see two separate insurance claims for the echocardiogram. One claim shows the echo, the other claim shows a physician charge AND another charge (for a different amount) for the echo. The bill from the hospital shows both charges for the echo under the same HCPCS code (93306) so I wanted to understand what the difference between them was in case one of the was a mistake. So far I haven’t gotten an answer other than “go ask [the other party]”.

My insurer is constantly messing up claims (and god knows my doctor’s office isn’t any better), and until today calling them has led to me saving a lot of money. (In fact I had another claim I called about today fixed because they messed up and they were very helpful about it!) It could be a totally correct bill and correctly processed claim but I just want to know that for sure. And maybe understanding what they mean about HIPAA limitations on discussing the bill will help me try again tomorrow to get answers!
posted by the thorn bushes have roses to Health & Fitness (6 answers total) 2 users marked this as a favorite
The Hipaa privacy rule prevents your doctor and insurer from discussing your medical care with third parties without your approval. You are not a third party here. The customer service rep was wrong.

Hopefully tomorrow you will get someone who knows what they're talking about! (One possibility is that one of the charges is for a facility fee.)
posted by basalganglia at 6:23 PM on July 23, 2020 [15 favorites]

The Hipaa privacy rule prevents your doctor and insurer from discussing your medical care with third parties without your approval.

You, on the other hand, are allowed to discuss it with whomever you want, including the insurance customer service rep.
posted by Dolley at 6:29 PM on July 23, 2020 [9 favorites]

This is the validation I needed!

Also OMG I bet it’s a facility fee. Why it costs an additional $750 is terrible but that does make sense to me.
posted by the thorn bushes have roses at 6:31 PM on July 23, 2020 [1 favorite]

a little OT but just a guess at the likely explanation for the charge breakdown on the echo: charge 1 is for the scan itself (you can think of this as paying for the room time and the machine time), charge 2 is for the tech (service component), and then the physician fee for the reading/Dx of the scan. there could be some other explanation of the breakdown but it is extremely common to see multiple bill line items attached to a single procedure unless you are in a situation with so-called "episode of care" billing where everything that happens during a hospitalization gets bundled, and this is not something that would typically apply for an outpatient procedure for someone with private insurance.
posted by slow graffiti at 7:23 PM on July 23, 2020 [2 favorites]

Furthermore HIPAA actually gives you the right to access your own health information including billing. See

That’s the point of HIPAA is that it gives you a range of information rights - privacy is just one.
posted by BAKERSFIELD! at 10:22 PM on July 23, 2020 [3 favorites]

I don’t think there’s any way a facility fee could be $750! At least I hope not.
posted by SLC Mom at 2:41 PM on July 25, 2020

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