Five Medical Bills You Shouldn’t Pay

If you are puzzled by a medical bill you’ve received in the mail, there may have been some sort of mistake that was made at your expense. It could be due to a lazy employee or an employee who doesn't understand the scope of their position. .

Patients are too often afraid of being sent to collections and/or receiving a negative impact on their credit report if they don’t pay a medical bill immediately. Providers and billing services have the ability to put an account on hold while a patient reviews or disputes a charge. Feel no shame in calling the agency that billed you to request that your account be put on hold while you determine what you are being billed for—you are not asking for a favor by doing this. You are simply substantiating the charges.

Listed below, are the top five erroneous medical bills a patient will receive. Not only have I seen these circumstances, but I have experienced it as a patient.

STUDIES

If you are participating in a study that your physician is part of, you should not be billed for the services—no ifs, ands, or buts about it. If you are being billed while participating in a study, you need to speak with either the office manager or the physician.

There are four phases of a study, ranging from phase I through IV. Depending on what phase the study is in, participants will often receive compensation. In every stage of the study, the manufacturer of the device or drug reimburses the physician for the amount of time spent with a patient and to fill out and submit necessary paperwork.

Patients are often billed for participating in studies that their physician participates in, because whoever is handling the billing doesn’t realize the office visit is related to a study. You should always keep your study records separate from your normal office visit records.

NO PRIOR AUTHORIZATION

This circumstance usually arises during an emergency, in which case you need to appeal the decision, or have the provider appeal the decision for retro-authorization with the insurance company.

If, however, you received the services from a provider you see on a routine basis, this issue needs to be taken up with the provider, and a call needs to be made to your insurance company.

Though provider’s offices will often say it is the patient’s responsibility to verify benefits and obtain authorization, insurance companies understand that patients are laypersons and, most of the time, rely entirely on a provider’s office to handle the administrative aspects of healthcare. You will need to stress to the insurance company that the provider in no way alerted you that authorization would be needed for the services and that you were given the impression you were receiving routine care. The provider’s office will most likely submit an appeal for medical necessity to obtain a retro-authorization for services.

This is something the provider’s office should have done when the denial was received; however, someone in the billing department was either too lazy or didn’t understand the scope of their duties.

NOT MEDICALLY NECESSARY

Usually encompassing the same circumstances as no prior authorization, the same avenue should be taken with correcting this sort of bill.

If the charges are in relation to a surgery or an inpatient claim, and some of the bill was paid by the insurance and some was denied, someone messed up—big time—and, most likely, you should not be responsible for the charges.

For example, though all surgeries, to the patient, seem like a big ordeal, the fact is that some surgeries are extremely simple. It is not unusual for a physician to assist with a surgery if he has nothing better to do on any given day, and he decides to hang out with his surgeon buddy and assist. Insurance companies will not pay for an assistant surgeon if the procedure is considered simple. You should not be responsible for this bill, and you should dispute it with the surgeon. A phone call should be placed to your insurance company if you are unable to remove the charges from your account.

With inpatient claims, hospitals employ nurses in charge of utilization review and coordination of care and benefits. It is that person’s job to notify the insurance company on a daily basis of your condition and not the ill patient’s responsibility. If there are denied days, the hospital needs to submit an appeal based on medical necessity. If the hospital is billing you for denied days, a phone call should be made to the insurance company in order to determine if the hospital is allowed to bill you. If you have insurance through an employer, sometimes enlisting the aid of the Human Resources Department proves to be an extremely useful tool in arguing with an insurance company to approve the denied days.

Lastly, sometimes providers will “upgrade” care or an item. For example, if you are receiving an orthotic device or some sort of durable medical equipment and it has some fancy features, it may not be covered by your insurance company. If the item supplied had been without the fancy features, it might have been covered. Patients are usually able to decide whether to pay for the additional features by paying out-of-pocket for the upgrade or inform the provider they don’t want the extra features. You might need to make a phone call to your insurance company if your provider’s office did not explain this to you and is unwilling to exchange an item.

If the charges are for a service that can’t be returned, a call should be made to the insurance company. Explain that you were not informed by your provider that the service would not be covered and that you were under the impression you were receiving routine care.

CONTRACTUAL ADJUSTMENTS

If your provider is a preferred provider with your insurance company, you should not be receiving a bill for the balance remaining on a service after the insurance company has paid the claim, unless it is for a copayment or coinsurance.  You will need to refer to your insurance company’s explanation of benefits to determine if you are being billed for contractual adjustments.

TIMELY FILING DENIALS

I saved the best for last, because it is so common. Did you receive a medical bill out of the blue? Is the service date a year or older? If so, this is probably because the provider didn’t submit the bill to the insurance company. Insurance companies have timely filing requirements, and if the bill was not submitted in a timely manner, the bill is denied. Often, providers will attempt to bill the patient, and these are charges that must be eaten by the provider.

You most likely signed a form with your provider that indicates a courtesy is being performed when they submit your bill. This doesn’t hold water when it comes to timely filing requirements (and often won’t hold water in relation to any sort of denial—they just hope you believe it). The form indicates that they are performing a courtesy, and at no time did they inform you that they will not perform the courtesy.

If a provider is billing you for an old service that has been denied by your insurance company for timely filing, don’t bother placing a phone call to the provider. Bypass the provider’s office, and place a phone call to the insurance company. If the person you speak with is not helpful, speak with a different representative or a supervisor. The insurance company will either hold a conference call with you and the provider, or agree to call you back once the issue is resolved.

More by this Author


Comments 16 comments

William F. Torpey profile image

William F. Torpey 6 years ago from South Valley Stream, N.Y.

Good information, Deni Edwards. It's important to remember that anytime you are dealing with the insurance industry that their interest is in maximizing profits. They do that in myriad inventive ways.


Deni Edwards profile image

Deni Edwards 6 years ago from california Author

yes, they do!

Thanks for visiting and commenting, William.


krishna vakati 5 years ago

Good info, I too follow the same


Deni Edwards profile image

Deni Edwards 5 years ago from california Author

Thanks for reading and commenting, krishna.


Ed 5 years ago

Those parasites i tell you...

Thank you for the info, saved me $650!


Deni Edwards profile image

Deni Edwards 5 years ago from california Author

Ed, I am so happy to hear that this info helped you--you just made my day--maybe my week!


Sandra Dudley profile image

Sandra Dudley 5 years ago

I just found this article and have to say that it is very interesting. Hopefully people take this advice and save money during their next medical visit.


Jan 4 years ago

Hi, I got a medical bill from a hospital for some services I obtained years ago. I provided all the info at the time, and they were going to bill to my insurance company. But the hospital failed to do so, and now the insurance company wouldn't pay it since it is way pass the time limit. So now I have to pay the bill myself. I asked the hospital for some discount, they refused. What should I do? Thank you.


Deni Edwards profile image

Deni Edwards 4 years ago from california Author

You need to call the insurance company and inform them that you are being billed. Your insurance company should then contact the provider and let them know that they are unable to bill you because of their error. The hospital will have to eat this charge.


Jan 4 years ago

Thank you for the advice. I will try as you suggested.


Josh 3 years ago

My mom was recently in the hospital and just found out her insurance company will not cover the charges because she didn't call them when she got to the hospital to let them know she was there. Can they do that? Do I have any options?


Deni Edwards profile image

Deni Edwards 3 years ago from california Author

Most, if not all, insurance companies require notification that the patient is in the hospital. This duty falls onto the hospital. Once the insurance information is taken, it is someone's job to call the insurance company, verify eligibility and benefits and ask about notification and certification requirements.

Again, this is the hospital staff's job. It is unusual for a patient to be able to contact an insurance company, sit on hold, be routed to and from departments, etc., while they are sick. Not to mention that if the patient did contact the insurance company, they would likely have no understanding of what is needed or access to the medical records and a fax machine to fax in medical documentation.

An insurance company has a contract with a hospital that usually indicates the hospital is not allowed to bill the patient--especially for something like this, when the hospital did not follow through with notification requirements.

Sometimes there are legitimate reasons for no notification, in which case these circumstances would need to be explained to the insurance company by, again, hospital staff.

It sometimes will help if the patient files a grievance and/or calls their HR person who handles the insurance coverage for the group. Because, keep in mind, the hospital should get paid for the care that it renders.

Again, this is not uncommon. The hospital where your mother received her care understands that this is how insurance companies work. There are accounts that will slip through the cracks when nobody on the staff notifies the insurance company. What happens? If the patient doesn't get involved and/or there is no reason why the insurance company was not notified, these charges are written off. This doesn't mean that if your mother files a grievance that the insurance company will pay for the hospital stay. It's up in the air and, again, depends upon the circumstances.

If your mother receives a bill from the hospital, or from any other provider, make sure to call the insurance company and complain. The hospital CAN'T bill you, it was the hospital's fault.


Vicky 3 years ago

My OBGYN Doctor wrote a prescription incorrectly for my mammogram and coded it as “medical diagnosis”, instead of “routine” which is fully covered by my insurance, and now I am being charged by the provider $535. I have been having the same routine checkups mammograms for the last 10 years at the same hospital, and when arrived at the hospital for my mammogram, I was asked by numerous employees what procedure I was having, and I repeatedly indicated that I was there to have my standard annual well visit for a Mammogram (which is fully covered by my insurance). I am not trained to read and understand prescriptions and at no time, any employee indicated that there was a copay or that any portion of the procedure I was having would not be covered by my insurance. I have made multiple attempts to correct the situation. I have called my Dr. who re-submitted the prescription with the correct code “Routine Checkup”. I have contacted the hospital multiple times and spoke with a Supervisor who said she would remove and recode the prescription and re-submit to my insurance company for payment. I have also contacted the Insurance Company where they refer me to contact the provider for resolution. Now I am getting a letter from an attorney attempting to collect the amount. Am I liable for an error made by my doctor? Also if the provider did not inform me of the procedure not being covered by the insurance company?


Deni Edwards profile image

Deni Edwards 3 years ago from california Author

It is normal for staff of medical facilities to ask over and over, "What are you here for today?"

This is because it limits mistakes--so a patient does not undergo a procedure that isn't supposed to occur. The staff probably also asked, repeatedly, for your name and date of birth.

If you have had breast cancer, a mammogram is no longer considered as a screening--it is considered a diagnostic procedure--and the cost for the patient will likely increase.

If you do not have a history of breast cancer, the procedure is considered to be a screening, and there should not be a charge for the procedure.

You need to become much more aggressive with this problem:

the customer service representative told you that you need to correct the problem with the provider, but you should not have accepted this as a resolution. You should request to speak with the supervisor, and keep moving up the ladder, until you are able to speak with someone who will help to resolve the problem.

What you want is a conference call with the provider, hopefully, the manager that you spoke with who knows that there was an error and that the bill (not the prescription) was coded incorrectly.

Now, in order for the bill to be re-coded to reflect that the procedure was for a routine mammogram/screening, the physician that referred you for the procedure will need to fax over the corrected referral form. The hospital or radiology clinic is unable to unilaterally change the diagnosis without the written correction from the referring physician.

So before you call your insurance company to have this mistake corrected, you should probably make sure that this has been done. If it hasn't, you need to take matters into your own hands, which would include calling the referring physician's office, obtaining a corrected referral (referring to the date of the mammogram), and sending it, either via fax, e-mail, or hand delivery, to the department of the provider that handles the coding (likely to be medical records).

Unfortunately, it is someone else's job to do all of this, but the people you have been speaking with are...lazy. So, it may be up to you to do this part, but since you now understand what is required to have the bill corrected, perhaps you could yell and scream at the provider to have someone else do it.


miamifife 3 years ago

I just received a billing from a provider for services provided 10 months ago! (Apparently there were 3 deductibles on my global insurance policy, and I had only met the outside-U.S. deductible, not the in-network U.S. deductible.) 1) Is there a time limit for the provider to pursuing charges from me? 2) If so, is it possible to negotiate with the provider on the amount? How would I go about this? I am now a retiree, so this unexpected charge is difficult.


Deni Edwards profile image

Deni Edwards 3 years ago from california Author

Since these bills are from a deductible, you should also have received some sort of notification from your insurance company (called an Explanation of Benefits). There are several reasons why a provider may send you a bill that is applied to your deductible many months, and sometimes a year even, after the date of service. One of the reasons is that it may have been initially denied in error by the insurance company and the provider had to appeal the claim--sometimes a provider will appeal a claim several times before it will finally be paid.

When this happens, patients will often have some out-of-pocket expenses that were unexpected since the services were rendered so long ago, and these charges are legitimate.

So, the first thing I would advise you to do is call your insurance company and verify that the bill has processed and that you are responsible for the amount the provider is indicating is your deductible. I would also ask your insurance company the date the claim processed. This will tell you whether or not the provider has been sitting on this bill for months or if it was just processed.

If the claim processed months ago--meaning the provider failed to bill you promptly--you could use this as a negotiation tool to ask for additional time to pay your bill or to make payments. Also explain to the provider that you are on a fixed income and the unexpected expense is a hardship. However, and unfortunately, if this is indeed a legitimate charge for a deductible, the provider is unable to waive this charge or reduce the charge.

    Sign in or sign up and post using a HubPages Network account.

    0 of 8192 characters used
    Post Comment

    No HTML is allowed in comments, but URLs will be hyperlinked. Comments are not for promoting your articles or other sites.


    Click to Rate This Article
    working