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We have received a couple of bills from a gastro specialist for office visits that seem high for the services rendered. Spouse went to regular Dr. and was referred over the next day after complaining about colon issues.
We have learned that the intitial visit was coded as a "New Patient Level 5 visit" which entailed about 20 minutes combined time with the nurse and Dr., and the recommendation for a celiac test and some blood tests. Celiac test was mailed 3 weeks later and the blood test was never scheduled or performed. $620 bill for this office visit (plus test cost).
Spouse was due for colonoscopy which she had done. Normal Billing. Dr. recommended coming back about a month later to see how things were going.
Spouse goes back and spends total 15 minutes with nurse and Dr. -- everything fine. Billed as an "Existing Patient level 4 visit". $360
My question is: after doing some research the way that their billing does not jive with what services were actually performed - or the required time spent with patient to justify the level of coding. It's like they are automatically putting these codes in no matter what and hope to get away with it. We have called the billing dept and they said "that is what they billed - we sent it to get reviewed and it came back confirmed as such". Our beef is that they did not do what they said they did to justify the level of coding for the bill.
How do you dispute this ? Called the billing dept - nothing. Went back to the office and they said "all billing is handled at our regional office - we can't do anything about it here".
We have received a couple of bills from a gastro specialist for office visits that seem high for the services rendered. Spouse went to regular Dr. and was referred over the next day after complaining about colon issues.
We have learned that the intitial visit was coded as a "New Patient Level 5 visit" which entailed about 20 minutes combined time with the nurse and Dr., and the recommendation for a celiac test and some blood tests. Celiac test was mailed 3 weeks later and the blood test was never scheduled or performed. $620 bill for this office visit (plus test cost).
Spouse was due for colonoscopy which she had done. Normal Billing. Dr. recommended coming back about a month later to see how things were going.
Spouse goes back and spends total 15 minutes with nurse and Dr. -- everything fine. Billed as an "Existing Patient level 4 visit". $360
My question is: after doing some research the way that their billing does not jive with what services were actually performed - or the required time spent with patient to justify the level of coding. It's like they are automatically putting these codes in no matter what and hope to get away with it. We have called the billing dept and they said "that is what they billed - we sent it to get reviewed and it came back confirmed as such". Our beef is that they did not do what they said they did to justify the level of coding for the bill.
How do you dispute this ? Called the billing dept - nothing. Went back to the office and they said "all billing is handled at our regional office - we can't do anything about it here".
Any billing pros out there??
Assuming these are services done by in-network providers, is your insurer willing to pay its share?
Upcoding is rampant, getting a correction very difficult - took these people a year - and they were medical professionals:
You might have to write them an email with everything written out . List all the procedures that got done, list price of procedure. Then list all the procedures that were not done, and for which you are getting charged. Also list price for that. Itemize each procedure so they don't have to hurt their pretty heads figuring it all out. Send them proof (a copy) of the procedures that were done that your doctor should of given you.
You won't get anything solved by simply calling them. Believe me, they will pass the buck to "the other agent/manager" and NEVER get it solved. And when this mistake on their part doesn't get fixed in due time, they will charge more because "you haven't paid yet". So it will then snowball on you unless you fix it fast.
Thank you for the replies. I have never heard of the term "upcoding" before but that is exactly what we are facing.
You have an uphill battle. If you're not on the hook for a lot of money and your insurer will pay most if it, may not be worth the time and energy to fight this battle - unless, of course, you're in the mood for a fight.
New patient office visit with specialist is always expensive,I had one back in 2003? and it costs me $175 and I paid cash.
Your insurer should reimburse you ,whatever the going rate is less deductible
You might have to write them an email with everything written out . List all the procedures that got done, list price of procedure. Then list all the procedures that were not done, and for which you are getting charged. Also list price for that. Itemize each procedure so they don't have to hurt their pretty heads figuring it all out. Send them proof (a copy) of the procedures that were done that your doctor should of given you.
You won't get anything solved by simply calling them. Believe me, they will pass the buck to "the other agent/manager" and NEVER get it solved. And when this mistake on their part doesn't get fixed in due time, they will charge more because "you haven't paid yet". So it will then snowball on you unless you fix it fast.
Good luck.
Her first visit is just with doctor and nurse in the office,there is nothing to itemise?
You have an uphill battle. If you're not on the hook for a lot of money and your insurer will pay most if it, may not be worth the time and energy to fight this battle - unless, of course, you're in the mood for a fight.
Good luck. Let us know what happens.
why did she not ask when she booked the appointment,how much is an office visit?It would dave her a lot of headache?
I always ask
There are, in fact, coding standards, and, in theory, the code should be supported by medical records. However, what's your recourse? Do you even have a dog in the fight, so to speak, since your insurer is likely responsible for most of the charges.
Have you received an EOB from your insurer? You are insured, not self pay? Assuming you're insured, you might look to see if there's a contracted rate that's much lower than what's been billed.
Yes, you are right that much of this is automated. It's probably less that they're trying to upcode and more that it's just not worth the time and effort to figure out the actual time spent on each patient, hence the use of "standard" codes for various types of visits.
One of the worst parts of our health care system is the setting of charges for various services, and the fact that the amount charged often has little relation to the amount paid unless you're a "cash" patient personally responsible for the charges.
One of rhe advantages of insurance, even high deductible plans, is that most of them have contracted rates with a lot of providers that are far less than cash ("chagemaster" in hospitals...) rates. You reap these savings if you play the game right.
As Ariadnee22 said though, is it worth a fight? The game is stacked against you, especially since billing codes (usually CPT) are a tool for third party billing. They don't really have any connection to what they bill you, which can, sadly, be anything they want to charge.
I could go on, but this gets complicated fast, with issues of allowables, balance billing, contracted rates and so forth.
Once I decided to get a mammogram since the last time I had one was 22 years ago.
I have insurance with deductible-Unicare (could be $3k),so I went to the hospital and they gave me one mammogram (Xray),then they said there is nothing to compare with so they recommend MRI.
The radiologist looked at the MRI results and said no problem,go home.
Then he wrote a letter to my gyne and said something funny is spotted and he recommended a biopsy.
Then the gyne suggested I should first see a surgeon ,I did.
the surgeon said you probably do not need surgery but get a biopsy.
So I made an appointment ,time is 6:30 am.
The day before the appointment,a lady from the hospital called me and asked me to pay $2200 as it would be too early tomorrow,no one would be there to collect the money?
And she preferred I pay with bank fund and she can do ACH and take the money from my bank account while we are on the phone.
So I asked how much is the total,is $2200 the final figures?
She said this is just for the hospital renting the room to me for the operation.
I have to call the radiologist to find out how much he would charge as the hospital contracted with an Indian company and the radiologist work for that company.
What about intepretating the results?
Well,there are 2 labs involved and I have to call each one to find out.
I tried to call each party and either the technician does not know or no one comes to the phone/
So I cancel the damn appointment and I am still alive and kicking 20 years later.
What I want to point out is -
All these people work for the same hospital,the gyne lease an office there so it makes sense for me to use the hospital service.
The surgeon just transferred from another city,his specialty is slicing breast meat
I dont want to say there is a conspiracy but hospitals and doctors all need revenue to pay bills,all these machines and people cost money .
Also the lady who called me for the $2200 have already studied my insurance plan and figure after this ordeal,I would have met my deductibles and any future services would be picked up by the insurance co.
I would not be surprised if I go thru the biopsy,they would find something else wrong with me.
So back to OP's problem,gastro problem is like a treasure chest,dont be surprised they will come up with more exams,tests !
Just my 2 cents
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