Common Medical Billing Mistakes – Part III: How to Protect Yourself

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TaekwonDoBeing aware of the most common ways in which the medical billing community makes mistakes can save you a lot of money. It’s important that a patient feels capable of reviewing his or her own medical bills and evaluating them for mistakes and feels comfortable enough to contact his or her own insurance company or doctor’s office regarding the mistakes found.

The Mistakes

Two common medical billing mistakes that are often found in patients’ bills are upcoding and inadequate documentation.

Upcoding Charges Upcoding is fraudulent medical billing. It is a practice by which a doctor or hospital uses improper billing codes and charges for a more expensive service or procedure than what was actually done. This is considered insurance fraud. It is not an accurate account of what occurred.

Inadequate Documentation An insurance company may deny a claim because there isn’t enough documentation to justify the procedure. Insurance companies want to know why a procedure was done, not just that it was completed. They want to know:

  • The diagnosis
  • How the doctor came up with the diagnosis
  • What symptoms the patient presented with
  • Why this particular procedure was done when other treatments may have been effective.

If an insurance company doesn’t get all of the answers they want, the claim could be denied. There is a simple solution to this problem—resubmit the claim with adequate documentation. But, as with other billing mistakes, once a claim is denied, some medical billers will simply bill the patient for the balance instead of resubmitting the claim.

Educate Yourself

The first step in empowering yourself in just about any area is education. The more educated you are, the more confident you’ll feel in tackling a problem. When you’re aware of the mistakes that are commonly made, you’ll know what to look for and you’ll know how to dispute what you’re being charged.

Read Your Statements

This may be easier said than done. If you aren’t a medical professional, attempting to read through a statement with a lot of medical jargon can be intimidating and confusing. In addition, billing statements are at times purposefully limited in the amount of information they provide. The hospitals and doctor’s offices are counting on people not asking questions, so if you don’t understand your statement, call your provider’s office and ask them to clarify the billing charges for you.

Call the Insurance Company

If you receive a bill for more than you were expecting, call your health insurance company. The statement you receive from your medical provider isn’t very detailed. So, you may not know what’s been billed to insurance, what is your portion, and if anything has been denied by insurance. In order to receive a detailed statement of your charges, you must request one. If you’re unsure about charges on your bill, contact the provider’s medical billing office. If you have questions about what was and was not covered by your health insurance policy, contact your insurance company.

When a claim has been denied, remember that this could be because of missing information or inadequate documentation. Ask your insurer why the claim was denied and what needs to be done to successfully resubmit the claim. You’ll be more prepared to take the next step after you talk to them.

Call Your Doctors or Hospital Billing Office

First and foremost, request a detailed, itemized bill of your charges. If you’re unsure of anything on your medical bill, call your provider and ask for clarification. They are legally obligated to accurately bill for procedures. If you catch a mistake, don’t be afraid to make this known to the medical biller. If you experience resistance from them, don’t forget that you have rights. There are many patient advocacy groups and attorneys who are happy to help you with a situation like this.

Take any relevant information you received from your health insurance company to your provider’s billing staff. Ask the billing staff if they have already started the process of resubmitting your claim. You may make them aware of a mistake that they hadn’t noticed and the issue might can be resolved quickly.

Keep Records and Follow Up

Whenever you have a conversation with your health insurance company or doctor’s office, document all you can about the conversation. Here are some things to make note of:

  • The name and title of the person you spoke with
  • The date and time the conversation took place
  • What was said
  • Let the person know that you’re documenting the conversation. Notate that you’ve made them aware of this, too.

Once you’ve talked to your health insurance company or provider, make sure to follow up after a few weeks if you haven’t received any word from either.

You don’t have to be a victim of medical billing mistakes or billing fraud. Through education and advocacy, you can see that you only pay what you truly owe. If you’ve followed these steps and still need help, contact Medical Billing Advocates of America at 855-203-7058 for assistance.

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