What do you do when you see unreasonable medical charges?

[trusso11783]

I want to a hospital last year because my finger was red and very painful. My Empire Ins plan pays all but $70 for an ER visit. Someone looked at my finger and said it was a MRSA Staph Infection and they had to call in a doctor it drain it. I waited about an hour. He did his thing.

About 6 months later, I got a bill for about $1500 from the doctor. I called and said it must be a mistake because my ins pays all but $70 co pay. They told me I had a $1000 deductible and owed the $1500. I told them there is no co pay. They told me that United Healthcare (my medical coverage that is not hospital visits) has a deductible. I told them I went to the hospital and it is Empire's responsibility to pay, not United Healthcare. They told me that they do not accept Empire, which is why they billed United.

I wrote him and the Hospital a letter asking why, after getting my insurance info when they admitted me, did they not match me up with a provider that accepted my insurance. I told them to work it out between them because as a consumer and a patient, at no time was I told that I was being treated with someone outside of my plan.

This all happened because the plastic surgeon that treated me felt his rates are double the going rate of all plastic surgeons in my area. End result, bill was squashed and disappeared.

[OhBeeHave]

Originally Posted by nuts2uiam

I would check the billing code again with insurer and ask the billing physician to explain the reason for surgery code. Then write a letter to insurer and explain the "surgery" and ask what code should have been used given the diagnosis of non fracture and a splint. You may get nowhere but at least you will have tried.

I am not a doctor nor an apologist for them, but I had tons of experience with medical billing when my mom was sick and often times denials by insurance were due to human error meaning a wrong code was put in on the claim. The best example I can offer was my mother needed a piece of medical equipment for survival, that in turn required sterile this and that to be used, each part was billed individually and paid for by her insurance. One of those things was saline solution and we kept getting denials, which made zero sense to me as you could not use this equipment without it. I finally called the insurer and explained it to the CSR who in turn explained that the coding by the doctors office was for wound care which was not covered. I had to call the doctor back and have then re code all the rejected claims. They screwed up.

I worked for physicians for a number of years and so much stuff was kicked back. One patient had a bilateral ear irrigation and the insurance company refused to pay for both ears. Why? The biller used the code for one side of the head twice as opposed to specifying right ear and left ear. (This was in 1989, I don't know if the codes have changed much.)

My grandmother had dropping eyelids which were impacting her ability to see. She had both lids raised and the insurance company denied it citing it was cosmetic. We had to fight it and prove that grandma's drooping eyelids covered her eyes!


The OP should contact the doctor's billing office first. There's a good chance someone might have entered a code incorrectly. If they won't do anything about it, then take it up with the insurance company.

[rocafeller05]

Exactly right Trusso. I know someone who was admitted when they went to the ER with chest pains. Got bills for $1,000's of dollars because the Drs were out of network. Now what were they to do...stop and ask every dr if they take their insurance while maybe having a heart attack? Or say hold on let me look at my book and make sure your in network? The system is so flawed.

[sbm7]

I don't know how many bill I had to fight because of e.g. lab address was wrong, doc didn't submit enough documents. And I had to stay on phone for hours to fix that which isn't my mistake to begin with.

As for the original issue, they said they lower the bill from 240 to 180. But to me it's still not reasonable. The doc said it's hairline fracture and there is nothing to he can do. He gave us metal splint for her finger and she took it off right away (she is 18 months old). I will call them back and keep fighting.