A billing expert investigated her husband's ER bill. She was able to knock thousands off the charge.

Submitted by 11ej25 t3_yiln41 in personalfinance

https://www.nbcnews.com/health/health-news/billing-expert-investigated-husbands-er-bill-was-able-knock-thousands-rcna53683

A skiing accident led to an emergency room visit — and an incorrect charge on the hospital bill.

If Dr. Bhavin Shah was on his own, he said, he probably would have paid the bill for his broken arm. The 47-year-old physician from suburban Chicago incurred surprisingly steep charges after landing in an emergency room on New Year’s Day 2021. He’d hit an icy patch while skiing with his kids in Wisconsin.

The $10,563.49 in initial ER charges from a Froedtert South hospital in Pleasant Prairie, Wisconsin, seemed high considering he basically got only an exam, X-rays, pain relief, and an arm splint. His insurer negotiated the cost down to $7,922.62 — but, with Shah owing $250 for his deductiblr and 40% of the remaining charges, his bill of $3,319.05 still felt like too much. However, he thought, who was he to question the hospital’s billing department?

Shah’s wife, on the other hand, is highly qualified to question such charges. Sunita Kalsariya, 45, is the office manager of her husband’s medical practice, a job that includes overseeing billing. She took one look at the hospital charges and decided to investigate further.

Kalsariya had no way of knowing then that she was embarking on a crusade that would take over a year, send their bill to debt collections, lead her to complain to the Illinois attorney general, and discover that the hospital charged nearly $7,000 for a procedure that was never performed.

This article talks about how difficult it was for a person who is extremely well versed in medical billing and coding to dispute a medical bill. Imagine how difficult it is for lay people.

I can already hear them saying that "well sir, splinting is treatment of an injury" and then hanging up before one could respond.

8,545

Comments

You must log in or register to comment.

keepingitcivil t1_iujeuhv wrote

Is there money in this? Imagine you hand your hospital bill or insurance claim to someone who reviews it and has it rebilled for a lower cost/high reimbursement. They could charge a percentage of the difference and probably make bank.

1,423

ktigger2 t1_iujgw53 wrote

I wish. I’m a medical coder and have helped family and friends with their medical bills. There is zero money in this. Believe me, I thought about it as a side hustle more than a decade ago.

For a $10 grand bill, I’ve negotiated and fought down several thousands. and…the patient still had several thousand to pay. In that case what could they have paid me? It’s be easier if the insurer or facility could do something, but no one is paying to advocate for the patient except the patient. And not a lot of patients have any extra money to pay someone to do that. Also to review a case took me hours or paperwork + time in the phone, PHI release forms etc. I make more at my regular job and it’s less frustrating.

886

Qbr12 t1_iujnk6q wrote

> For a $10 grand bill, I’ve negotiated and fought down several thousands. and…the patient still had several thousand to pay. In that case what could they have paid me?

Take a cut of the difference. If you agree to a 10% cut, and you drop the bill from $10k to $5k, you saved them $5000 so you get paid $500. Your friend is happy because they save $4500 and you are happy because you get $500! That's a sustainable business model if I ever saw one!

288

ktigger2 t1_iujojrp wrote

That $100 also took me hours of work, phone calls, digging through their medical policy to make sure they had coverage (or didn’t) plus reviewing itemized billing. I’ve totaled up my time for when I’ve done this, especially complicated cases with high dollars and I’d make more at a minimum wage job. I did seriously look at this as a business model, it’s not profitable.

500

Qbr12 t1_iujqfcq wrote

Should be $500, I flubbed my math there, but I understand what you're saying. Sometimes the juice isn't worth the squeeze.

138

falco_iii t1_iujulvj wrote

It would require streamlining and automating the process as much as possible. Have a notary ready, have a checklist of actions to take & have a lower wage assistant to do the basic steps, learn what bills normally look like so you don't chase after crumbs, etc...

23

ktigger2 t1_iujw44i wrote

LMAO at streamlining anything in regards to medical insurance in the USA. There are 4 employees that are billing related to every provider, and that’s just on the medical side. Medical insurers all have different billing systems, EOBs with info in different spots. Same with providers. You are investigating if it was billed correctly (documented correctly) and or paid correctly. Everyone answering here telling me you could make a living doing this for work has never worked with medical billing. But you are all giving me a nice laugh today.

154

fuddykrueger t1_iuk7pdy wrote

I know. I worked for a doctor who paid me a whole $20/hr (before taxes) to chase down insurance payments from his patients’ denied claims. I made him way, way more money per hour than what he paid me for my time and frustration.

40

ktigger2 t1_iuk8enr wrote

I helped work denials for a clinic as a part time gig. I found them way more $ than they paid me. I feel you! Now that I would have done for 10% of what I earned for them and still made bunk.

22

saltoftree t1_iujutrh wrote

What exactly would the notary be doing in this arrangement?

15

ktigger2 t1_iujw5f0 wrote

Nothing. It wouldn’t be necessary.

13

falco_iii t1_iujwvbo wrote

Notarizing the patient's request for full medical records, as per the article.

4

ktigger2 t1_iujxfx0 wrote

Requests for records do not need to be notarized.

17

The0nlyMadMan t1_iujymxm wrote

If a third-party is requesting your full medical history on your behalf it makes sense to me to have the request notarized

−10

ktigger2 t1_iujzuhp wrote

HIPPA doesn’t require medical record requests to be notarized.

7

The0nlyMadMan t1_iuk2lx6 wrote

I never said they did? I just said it makes sense. For sensitive information like that, I would understand it being a requirement.

−8

cheesegoat t1_iuk2y2i wrote

Perhaps people could pay a recurring membership, you pay for their medical bill in full and then whatever you fight down reduces your cost? Incentive for you is to reduce as much cost as possible to make sure the membership fee is profitable.

You could call it... insurance insurance.

29

ok_itz_zae t1_iuk869e wrote

It's weird to me that someone would be able to make money from something that is made up.

It takes someone minutes for someone to create an incorrect bill... then it costs you your most valuable resource, your time and another valuable resource, your money to get this resolved.

If you got a fake bill, you would consider it stealing if you paid it. Attempted theft if you didn't.

It would be better to take these money loving doctor offices to court or find a better way to hold them accountable...

19

Fausterion18 t1_iuk6m16 wrote

$500 is about the cost of an auto broker who finds the car you want and negotiate a deal for you. And often they have pre-negotiaged deals with specific volume dealers.

This is maybe a couple hours of work per client at the most. Compare it to negotiating a hospital bill which could take tens of hours.

18

jgengr t1_iujtlf4 wrote

Could the commission be subsidized by a non profit? Or get paid hourly by non profit and get a commission off of what is saved?

10

ktigger2 t1_iujxss9 wrote

That would be a thought and one I looked at when it was considering doing this. But what nonprofit? You need one already involved with medical services and has a way to find this clientele plus pay someone to do this. I stopped there a decade ago. Maybe when I retire I’ll volunteer somewhere but for now medical coders are in demand and we can make more working regular medical coding gigs.

12

DesertTiger26 t1_iuk3rii wrote

If a lay person needed to fight $20k in out of pocket medical bills, what would be the best approach? My partner has a total of $12k from around 8 different medical providers and my son has $8k in medical bills from 4 providers. All within the past 12 months. Needless to say, there is over 50 EOB between the 2 of them. I would love to hire someone like you if possible.

52

ktigger2 t1_iuk5isx wrote

Start with your insurance policies. Does it look like they were covered appropriately per what your policy states? Get itemized billings from the medical providers and check the COT codes and descriptions against what happened at the visit. Get the records if necessary to compare documentation against what was billed. Call the medical provide and ask questions. Call the insurer and ask questions. That’s where I’d start.

63

ghalta t1_iujhzy5 wrote

It's not impossible. I pay a law firm to protest my property taxes every year. If they reduce the declared value of my home, and that results in a reduction of my property taxes due this year, they take as payment 50% of the amount saved. If they don't get it reduced, or they do but it doesn't affect my taxes (which happened this year), they get nothing. And, I get all of any compounded benefit for future years.

The big difference I see is that, after signing over the limited POA paperwork to them, I'm a continual client until I withdraw. For medical billing, there'd be a lot more time required to chase after customers with bills big enough to be worth the effort.

45

ktigger2 t1_iujisfs wrote

But the clientele for this group is mainly people with high deductible insurance policies or no insurance. Not really the clientele that keeps lawyers on retainer.

98

ghalta t1_iujqeax wrote

It's also people who get hit by large out-of-network emergency balance bills in states where those are still legal. I'm not sure which states that's true for though.

16

TheSacredOne t1_iujsdu6 wrote

That isn't legal anywhere anymore. Out of network billing / balance bills for emergencies were banned federally back in January (see No Surprises Act).

26

ghalta t1_iujsmbl wrote

Cool. So the story this thread is based on is probably no longer relevant to anyone. (I don't think the story says that the patient owed 40% because it was out of network, but that's a high percent for in-network coinsurance so I assume so.)

3

adultry-throwaway t1_iujxb6p wrote

In all honesty the hospital should be held more accountable. Build out a non for profit to help these people. The non profit helps checks gor over/double charges on their clients bills. Put the hospital on the hook to pay the non profit an amount equal to what they over charged their patient.

If nothing else the hospital will be held responsible for their mistakes.

2

bassman1805 t1_iujojp0 wrote

Do you mind sharing a little bit about your arrangement with the law firm to reduce your property tax? It might be a little personal for a public forum, but what's your property worth and/or how much have you been able to reduce your yearly tax bill by? How'd you go about finding a lawyer with experience in this field?

I'm a new homeowner just learning the ropes with property taxes. And I've never hired a lawyer before.

14

ghalta t1_iujrtwk wrote

It's pretty common at least in Texas. ProTax (not the company I use) is one of the biggest in the market. Texas isn't a low-tax state; it's in the middle, but with no income tax, a lot of its revenue comes from property taxes. This includes school taxes, which the state takes, redistributes some of, and then uses the rest of balance the general books. So there's a lot of money to be made in small reductions in property value.

My tax rate appears to be like $2 per $hundred in valuation. So, if the appraisal board says my house jumped like $60k in value this year, that's an extra $1200 I'd owe. But the lawyer uses comps (which they found for lots of clients) that show my value should have only changed by +$20k. They protest, spend maybe 30 minutes total on my case (I assume), and get my valuation fixed. The difference in $40k valuation turns into $800 saved on my taxes, so I pay them $400 for their time and I pocket the other $400 they saved me.

Some years the county tries to up my valuation by $150k or more. This year it was a lot more than that. They got it lowered some. Texas caps your valuation change for the purpose of taxes at 10%, so if the county says my house doubled in value in one year, the double value shows up on the books, but I only pay 10% more. Then next year I can pay a compounded 10%, etc, until I catch up. That's why it pays to protest every year. The past five years when they got my value down $50-150k each year means my starting point for the cap is lower.

31

rbekins t1_iujqlmt wrote

You do not need a lawyer to reduce your property taxes, or to fight increases. Talk to your assessors office about the process and it is something you can do. There are different methods of appealing based on the why your assessment is changing, ie a reassessment or equalization.

Here when it is a reassessment there is the option of talking to the assessor and having them do an informal assessment, basically coming out and walking around the property and giving you a number. You can either agree with the number or disagree. If you agree with the new number you simply sign off and its done. If you disagree you can still do a formal written protest to the board of review.

If the increase is a result of equalization, your only option is to submit a formal written protest.

When talking to the assessor, or in your written protest tell why your taxes should not be increased. For example one time I argued that my taxes were being increased twice in two years while other houses in the area were not. Another time i protested that the increase was greater than what other houses of similar age, size, and design were selling for in my area.

11

peter303_ t1_iujymg3 wrote

Similar to people who appeal their denial of Social Security Disability application, which happens over half the time. The law firm takes a fraction of the back-paid SS, if successful. Typical appeal takes couple years. If the appeal is successful, you get get bak-pay to time of application.

9

Manojative t1_iujos3y wrote

If I had a 10k bill and you brought it down to 3-4k. I would happily give you at least 30% of that 6-7k you saved. Don't know if that would be worth your time, but with enough numbers I think it make for a good living..

11

Flame_Effigy t1_iujysju wrote

If I can't afford a 10k bill I don't know if I'd be able to afford the 3k along with a commission. That's the problem here. The bills are so outrageously inflated and expensive to the point where people can't pay ANY of it.

24

bedroom_fascist t1_iuk3c4s wrote

It really doesn't. You're talking about ~$2k ... for ... how much time and effort? to say NOTHING of overhead?

Healthcare has become a financial scam, and all the players know it. They are complicit.

13

JudgeHoltman t1_iujrbnr wrote

> In that case what could they have paid me

10% of the $100k you saved.

Cheapest rate is $200 flat rate for you to go through the bill and give them a crash course on who to call and play secretary tag with, along with some magic words.

Or for $50/hr, you'll do a polite bit of identity theft (or do the paperwork) and make the calls yourself.

Imagine how much more effective you could be if this was your full time job and could make calls all day during business hours.

You'd be even MORE effective if you had the time and motivation to show up at the billing department in-person and just do the damn thing.

If you're good at it, you could probably partner with a Law Office as one of their paralegals and do the whole thing legitimately.

4

ktigger2 t1_iujxbvs wrote

Again someone who had a high deductible insurance plan most like doesn’t have a couple hundred around to pay someone to do this. This clientele with money to pay for this service doesn’t exist.

20

CorporateDroneStrike t1_iuk881z wrote

I’ve read your comments and I can you’ve got a lot of insight into this…

At first, I wanted to argue with you like everyone else but I think you make a good point about the high deductible or uninsured group.

I think there are surprising amount of people who could pay a reasonable fee to (20-40% of savings) to avoid excess spending — but they have lower deductible policies with an out of pocket max.

My deductible is $1500 and my out of pocket max is $4000. I’m fortunate enough to be able to pay the max if I needed to (fingers crossed any accident happens at the beginning of the year) but I don’t have the incentive to fight over billing because insurance will kick in.

I think there are 2 problems: target market and really high specialized labor costs for investigation. I think you could bring down labor costs with a really good tech system (machine learning maybe) but that would require investment.

It’s tough.

3

Trottedr t1_iuk0wad wrote

Some state agencies offer services like this, at least to find out if the billing is compliant with state regulations and the insurance company has paid the appropriate rates according to the insured's policy.

2

TheKerui t1_iujs3pi wrote

The answer is to get hires by the insurer to reduce their costs on a much larger scale.

3

ktigger2 t1_iujwol4 wrote

Insurers already do this for their benefit and when they are stuck with the bill. If it’s a high deductible plan and the patient is liable they aren’t spending their time and money on this. If they are footing the bill it’s another story. I’ve been in this field for more than … !! 30 years, I’ve worked for a hospital, private practice, specialty center and now am on the insurance side.

8

ChuCHuPALX t1_iuk5r2j wrote

There's money if you threaten to sue and get a settlement.

3

riptidestone t1_iujy2gp wrote

I notice Labcorp is up to thier usual crap again.i went to my doctor's office and had my blood drawn by HIS nurse to be sent to lab corporate. Lo and behold what was on LabCorp's bill a venipuncture charge for $25.00.

2

Brando_Calrisian_ t1_iuk2z5r wrote

As a side question, my wife is looking into getting the certs to be a medical coder. Do you think it's worth it?

2

Kihr t1_iuk6wbl wrote

I'd give you a 20% finders fee

2

ktigger2 t1_iuk7tjs wrote

And if I do all the investigating and don’t find anything I just wasted a lot of time for zero dollars. Not all billing is nefarious or incorrect. I’ll keep my day job.

6

Reach_The_Beach t1_iujopdk wrote

In my case at one employer I worked at, we had a benefits coordinator in HR who was worth her weight in gold. So her main job was supposed to be running all the open enrollment and making sure everyone’s insurance needs were taken care of. I’m sure there’s more to it, but it felt like she went above and beyond. She probably spent 30-40 hours a week on the phone with our insurance provider and the hospitals/doctors offices fixing these issue.

I had numerous times where I thought something should have been a co-pay and I got charged $300 or something that should have been like $200 getting charged as $1000. In every instance, she fucking lit into people until the claims were processed properly. She saved me thousands in the few years I worked there. Can’t imagine how much money she’s saved employees there over the 30 years she’s been there.

417

tx_queer t1_iujyg4f wrote

Same here. Got a surprise bill in the ER. Talked to the hospital, no luck, apparently I signed some paperwork while half way unconscious. Talked to the doctor-helper, no luck, apparently I met him while counting down from 10. But the benefits coordinator went on a 6 week crusade and was able to get me my $4000 back

234

Reach_The_Beach t1_iujz10a wrote

HR departments typically have a lot of bloat and unnecessary positions, but man oh man the benefits coordinator (assuming it’s a good one) sure ain’t one of them. If I owned a company I’d probably pay them twice the market rate just because I know how important a good one is to my employees.

132

frankbeans82 t1_iujhyk1 wrote

She spent a whole year on this (obviously not literally) fetching itemized bills and medical records. She only saved $2100 in the end. She'd probably have to sue them to get some kind of damages.

44

shadow_chance t1_iujrsu3 wrote

It's interesting it took months to even get the CPT codes. In their case, their insurance processed the claim seemingly quick. Their EOB should have had the codes.

13

sold_snek t1_iujvfka wrote

> lead her to complain to the Illinois attorney general, and discover that the hospital charged nearly $7,000 for a procedure that was never performed.

My question is how is the hospital not being sued or investigated for what sounds like blatant fraud?

42

blablahblah t1_iujkory wrote

There's two problems:

  1. Insurance is paying most of the cost anyway so you're only saving the client a fraction of what you fight, so a fraction of that isn't going to be especially big compared to the effort you spend and
  2. Insurance plans have a max out of pocket so there's an upper bound on how much you can save any client. And if they hit the cap, you may have to fight thousands of dollars in charges before you can save your client a single penny.
19

Awhodothey t1_iujnned wrote

Also, most people aren't getting charged for procedures that didn't happen.

6

ForeverALone_Ranger t1_iujfzuc wrote

I was thinking the same thing. It seems so (unfortunately) obvious that I can't imagine no one does this yet.

13

it_helper t1_iuk2o4v wrote

Yes kind of. My dad is retired and works part time for a company that audits this exact scenario. When there is a delta between what insurance thinks should have been charged and what the hospital bills for, his company goes in and audits everything. Anything they find that saves their party money, then the company he works for gets a %. You would be surprised how much his company found was incorrectly billed or charted.

9

shadow_chance t1_iujqygz wrote

I don't know much it actually works, but my employer has this service (I think it's through their insurance broker?) where we can submit bills and a "specialist" is supposed to be able to assist with questions or explain charges. Not sure if they have some inside line to our insurer or not.

5

upstateduck t1_iujqvgj wrote

the money is on the other side ie teaching hospitals/doctors how to maximize their revenue through coding manipulation

4

epsdelta74 t1_iuk4l1z wrote

There is. I used to audit Pharmacy insurers and we had some very loyal clientele. Usually the amount we recovered for the client paid for the audit!

Of course, there is a ton of resistance to even getting an auditable contract signed. Truly auditable, not another version of the auditees "correct because they know" report.

4

luger718 t1_iuk3o32 wrote

My job offers this through Justworks (the payroll/benefits provider) it's called Healthcare Advocate, they help you with understanding health plans and such but also have a service where they negotiate prices and keep a cut of the saved money (I think 25%)

2

Katelynfinesse t1_iuk4nvu wrote

There is now software that does this for medical practices, I am a sales rep for one of the top ones in this industry. Before I learned about the rev cycle in healthcare I was blown away at how tedious it is, especially the denials and appeals process of medical billing.

2

Mr_Ted_Stickle t1_iujymav wrote

Look at you thinking about making money off of someone who was incorrectly billed by a hospital. Imagine if hospitals were just honest and billed appropriately. Woooaaahhhh.

−3

yeah87 t1_iujq6id wrote

An underutilized benefit some companies offer is a Benefits or Health Advocate. I basically call them about any questionable issues on my bill, give them permission to speak on my behalf, and they spend the day on hold and figuring out what's up. Sometimes there's nothing wrong, but they can at least explain what's going on to me.

1,288

ziibar t1_iuk3p7e wrote

I agree with this 100%. I recently had a claim denied without reason (we had pre- authorization even), and after I reached out to my company's Benefits manager, they had the claim paid in 4 days. I was shocked at how easy it was.

The Benefits team speaks for all the employees signed up with the insurance company... That can be a huge amount of leverage.

392

Raisin_Bomber t1_iuk5ddo wrote

The leverage scales with the size of the company too. At my major uni of 30,000 employees, some say the benefits coordinator holds more power than the Board of Regents when it comes to dealing with the insurance company.

144

alienman t1_iuk6rhr wrote

Oh wait. I thought Benefits was just the division of HR that merely manages contracts and accounts with benefit providers. I didn’t know they offered advocacy!!

129

blorpblorpbloop t1_iujryag wrote

>discover that the hospital charged nearly $7,000 for a procedure that was never performed.

How is this not straight up fraud at grand-theft levels?

528

upboatsallaround t1_iuk4gpf wrote

It absolutely is, but when you have the bribes lobbying power these insurance companies do... it magically isn't.

218

Jeutnarg t1_iujwkru wrote

It's not legally fraud if it's a simple accident. In my state, it has to be done "intentionally, knowingly, recklessly, or with criminal negligence" to count like that. That's just one state, but it's probably similar in most US jurisdictions.

Now, if they try to keep it after becoming fully aware of the situation, you could be looking at a crime.

138

PA2SK t1_iuk5c7t wrote

The thing is it probably is intentional, or at the very least willfully ignorant, but proving that would be next to impossible without a whistleblower. It seems like hospitals routinely issue outrageous bills and then chalk it up to a "mistake" when they're called out on it. The strategy seems to be to pad the bill as much as possible and then let the insurance company/patient argue it down if they're so inclined.

115

[deleted] t1_iuk4jw7 wrote

[removed]

73

GoBanana42 t1_iuk7kr0 wrote

A mistake or typo on a bill is not the same as ignorance of the law.

23

Unsteady_Tempo t1_iuk870i wrote

See also discrimination. A business can have a pattern of discrimination due to institutionalized policies and practices and not because any one individual is making a conscious, nefarious decision to discriminate against a protected class

9

Warmstar219 t1_iuk5obw wrote

It is. But people with money play by a different set of rules.

43

Unsteady_Tempo t1_iuk7v6q wrote

It should be, if there's a pattern of it. The hospital admitted they coded it as a treatment of a fracture rather than a stabilizing splint. The patient didn't receive treatment of the fracture until the following day at a different, unaffiliated provider.

Shah received a letter from the hospital dated May 27 of this year, saying it had reviewed the records and discovered the bill was inappropriately coded: The hospital should have used the code for a splint, not a treatment. A month later, Shah got a new bill with a patient balance of $1,214.91 — $2,100 less than the original balance.

12

[deleted] t1_iujw0g9 wrote

[deleted]

424

CheeseWheels38 t1_iuk6xee wrote

>his absolute lack of surprise made me think he just hopes people who have insurance don't look too closely at the insurance statements.

This is about 40 percent of all the bills I've received this year.

223

DW241 t1_iujeirr wrote

I was hit by a car in June ‘21 in CA while on my dad’s bike (I no longer live in the states). It took until 2 weeks ago to collect all the bills from my ER and follow visits due to how terrible the billing system is. During this time, I was sent to collections for a very small missed invoice and it tanked my credit. The total ended up to be like 180k but the lean holders agreed to “settle” for like 120. Luckily it was the lady who me’s fault so her insurance paid for everything. But still…..It’s such a fucking racket.

314

sem1845 t1_iujfd0f wrote

1st comment was edited to make it clearer when everything happened. I stand corrected and the timeline is much clearer now.

38

resorcinarene t1_iujg29d wrote

He didn't say that. He said it happened in June and updates as of 2 weeks ago he was to collect all the bills

10

sem1845 t1_iujgg33 wrote

Comment was edited and is much clearer now and the timeline makes sense.

7

MoreRopePlease t1_iujicu2 wrote

I made the mistake of going to my regular clinic to get an optical exam for new glasses. I told the person at the counter I was using VSP, and that nothing was wrong with me, I just needed new glasses.

They still set me up for a medial eye exam, not a regular one (at the time I didn't know there was a difference). VSP doesn't cover that. And since I had in fact gotten a medical eye exam, I had no recourse. I was so pissed off at having to pay for the exam that I was expecting to get for free... (and a medical exam costs a lot more than a regular one)

278

11ej25 OP t1_iujloj3 wrote

Couldn't they have billed medical insurance instead?

52

MoreRopePlease t1_iuk5zi9 wrote

I have a High Deductible plan. They billed, yes, and there was a very small discount. But I had to pay the rest out of pocket. If I had known/understood they were giving me a medical exam, I would have declined and gone to America's Best.

At the time, I had no idea there were two different kinds of exams you could do, so I didn't even know enough to ask the right questions or say the right magic words.

56

boadicea-h5 t1_iujyvid wrote

Most medical plans specifically exclude eye conditions like farsightedness, etc. If you have an eye infection or injury, your medical could be filed. Otherwise, not.

27

onetwentyeight t1_iujlnt6 wrote

Does your health insurance cover medical eye exams? I don't know the differences between the type of exams. Still, given that health insurance tends to cover ophthalmological exams and procedures since they are "medical," perhaps there is a way to get that cost covered given your current insurance coverage.

For example, I had an eye infection and saw an ophthalmologist, had an ocular ultrasound, had lab work, and got some prescriptions, and they were all covered by my PPO plan.

40

boadicea-h5 t1_iujyrol wrote

Your medical covered it because you had an infection. Most medical policies exclude eye conditions like farsightedness, nearsightedness, etc.

26

Kuhnhudi t1_iuk1ziy wrote

VSP basically covers a “here’s your glasses prescription.” Anything else with the eyes (bumps, infections, aches, etc) are medical. Call the office back and ask why you’re charged as medical? I went to my PCP for an annual physical and mentioned a knee ache. It wasn’t an annual exam anymore and I was charged as such. Just saying there’s more nuances to insurances than most people may realize.

17

MoreRopePlease t1_iuk6rrf wrote

> Call the office back and ask why you’re charged as medical?

I did that when I originally got the bill in the mail, because I was very confused. And they said the procedure I got was a medical exam, so the billing was correct. I don't recall the exact words, but they told me I should have asked for the regular exam.

It seems to me that the person behind the counter should have been a lot more careful to make sure they understood why I was there and what kind of appointment they were setting for me. I had no idea there were two kinds of eye exams, and I've been wearing glasses my whole life.

15

tinyrbfprincess t1_iujqnnw wrote

Do you have a medical dx? Cataracts, glaucoma, lattice degeneration, or diabetes? Some eye practices automatically classify you as medical if you have a medical dx

ETA the list is for example, there are many different medical dxs where the eyes are concerned.

4

MoreRopePlease t1_iuk6f79 wrote

At the time, I had no complaint. I just needed a routine exam so I could get a new prescription (and determine if I needed progressive lenses yet). The exam resulted in no Dx either.

I have a high deductible plan, so they billed my insurance, and I still had to pay. When I called the clinic to question the bill, they said "it was a medical exam, there's no billing error". And even though I told the person behind the counter exactly why I was there, they didn't clue me in there there are two different kind of exams. And the exam they gave me was not the kind that VSP would pay for.

How are people supposed to learn all these nuances?

I could have gone to JC Penny and paid nothing.

16

earthwarrior t1_iujndpi wrote

It's sick that you even need to do this. Imagine all the time she spend on this.

110

killshelter t1_iujr4wu wrote

Isn’t that fraudulent of the hospital?

84

portagenaybur t1_iujwbz6 wrote

Yes. But there’s no recourse or any law against it really. People/insurance are overcharged all the time in healthcare. It’s the US’s greatest grift.

118

HadesHimself t1_iujwnf8 wrote

Fraud requires intent I'd guess right? Hospital can easily claim it was an honest mistake on their end, which they corrected when the couple notified them of their mistake. We'll never know whether it was truly accidental of course.

34

boadicea-h5 t1_iujz9lb wrote

It does require intent. I'm a medical coder and biller. We make mistakes. If we are notified and correct it, it's not fraud. Typos happen. We are legally obligated to notify insurance companies of these mistakes so the medical record they have for the patient is corrected as well. It's very easy to make a mistake. We try not to, though.

17

Rikuskill t1_iuk0whj wrote

I just wish there was some more transparency in this situation. It shouldn't have taken a year to discover the fraud. The data should be quickly available, and if not then the charge should be dropped, no?

27

Johnny_Lawless_Esq t1_iuk6sjh wrote

Intent is a key element of fraud, and proving intent would be very difficult in this case.

25

kangaroo312 t1_iuk5a5w wrote

NPR has a monthly series called “Bill of the Month” where they do a deep dive on a surprising medical bill. If you’re looking to learn more about navigating our bull shit healthcare billing system, I highly recommend it. The article is usually about 50% the story in particular and 50% “what you can do”/tips and tricks. I hate it yet it’s so good.

One particularly egregious article was on someone who was bitten by an animal and went to the nearest ER for a rabies shot. They overcharged them a TON and the “what you can do” section of the article was basically “welp, you HAVE to get rabies vaccine ASAP so you can’t cost compare ahead of time and you are supposed to go to the nearest provider as soon as possible.”

My take home message is for a dumb bill to get resolved, you always to get a journalist to cover the story and shame them…but only like <1% of people can do that…

73

mimic751 t1_iujn53f wrote

What is absolutely insane is that my wife has worked in health insurance for years and I honestly don't know how I would get all of my claims processed correctly if it wasn't for the fact she has years of experience with it. We save thousands of dollars per year getting our charges properly applied to our coverage

66

shanghaidry t1_iujvxqb wrote

Why not get better insurance?

−24

andrewsmd87 t1_iujw9el wrote

For most people this is tied to their jobs and you don't have a feasible option to do so.

50

shanghaidry t1_iujx3e6 wrote

Good point.

9

IAm-The-Lawn t1_iuk788j wrote

There’s always market place insurance, where you can shop around for coverage, but getting better coverage than your employer offers is going to be incredibly expensive relative to what you pay with your employer.

6

ednksu t1_iuk733j wrote

There should be a law that if you catch some fraud like this you got a percentage as a reward like you do with tax cheats.

55

gaoshan t1_iuk867v wrote

This is part of the problem. Even finding out the bill was inflated and then fixing took a year. Probably tons of phone calls and emails, tons of back and forth and extra stress… it’s ridiculous. I have a situation right now, myself, where I got Covid and started coughing blood. I actually called my insurer (as I’m holding tissues with blood clots I had just coughed out) to ask which ER I should go to (so I do t get raped by some out of network place). They tell me, “This is an emergency, don’t worry about it. Just go to the closest place”. Well guess who just got a huge bill for that visit. Fuck these people. Now I have to spend time and stress trying to fix things (meanwhile I’ve already been sent to collections). It’s ridiculous, unreasonable, unfair and complete bullshit. How is our system so screwed up?!

54

portagenaybur t1_iujwmbb wrote

Took us months to remove charges for pediatric Covid shots. That were supposed to be free to begin with.

53

revutap t1_iujnl48 wrote

Now my question is, how many times has her husband's private practice that she's overseeing done the same thing to other poor innocent families who doesn't have the same skillset as her to not only recognize the erroneous bills but successfully argue on their behalf?

41

Seraphenrir t1_iuk6nyg wrote

Private practices of a solo or small group of physicians aren't the same thing as large corporate ER's/Hospitals. Speaking as a physician, if you screw your patients with large surprise bills, they're going to quickly lambast you online and switch to another physician. Not exactly the best way to build a successful business. Private practices generally are for specialties that typically deal with elective complaints, where the problems aren't urgent and you have a choice of who to see. Whereas if you're a large ER or hospital, most if not all of your patient's are in some sort of emergency or urgent condition and don't have any choice but to be in your hospital, without much say in the matter.

We get little to no training on how to bill for our services in medical school or residency. Most of the time we have to get lectures on how not to underbill for what we're doing.

The other point to consider is that fraudulent billing is serous. The fines are repercussions are massive, including being cut off and banned from those insurers or Medicare/Medicaid entirely.

30

revutap t1_iuk71m3 wrote

Thank you for your response. I’ve learned something.

4

upstateduck t1_iujrnyk wrote

exactly, the common "billing consultant" advises doctors/hospitals how to maximize their revenue through manipulating codes for payment

17

ambulancisto t1_iuk8kd9 wrote

Not much I suspect. Do that with a Medicare patient and you fall under the False Claims Act: a civil war era law that punishes people who overcharge (i.e. defraud) the government. It encourages whistleblowers to turn in their companies/bosses, because the whistleblower gets a cut of the recovery. I saw a doctor get fined $800k, plus had to pay back all the profits, for ordering nonFDA approved chemo medicines from Canada to give to his patients. I'm sure someone in his office turned him in.

5

BaronCapdeville t1_iujq6vf wrote

Ok.

Why is this your question?

−9

revutap t1_iujqfk9 wrote

Because of the lack of transparency in medical billing. I simply have my own personal doubt that this is not something that has been done at their own family practice.

I am not looking for you to think like me nor agree with my line of thinking.

11

GailaMonster t1_iujqtqm wrote

I only feel competent to challenge bills because my father was a pathologist who literally started his own medical billing company so he could control the middleman who screwed this shit up constantly.

Literally had to be my family business to know how to fight this shit, same as OP. the system is 100% rigged when only doctor's children and spouses and those in the medical administration industry can get fair treatment.

40

grootdoos1 t1_iuk3wsk wrote

I spent 8 months fighting a 450k hospital bill with Froedert. End up paying $1750 out of pocket. It was exhausting and spent at least 20hours a week. It can be done if you are tenacious and patient. Best advice is never yell are talk down to the employees on the other end of the phone.

35

ChewWork t1_iujqyyo wrote

My daughter hit her eyebrow on her bed at like 9pm on a Sunday (no urgent care was open). It was questionable on if it needed stitches and I didnt want her to scar so we played it safe and took her to the ER. They ended up just super gluing it shut...We just got the bill today and the hospital charged $2,900 for super glue and to check her blood pressure.

30

CentiPetra t1_iujzre9 wrote

My daughter broke her arm a couple months ago. They did a reduction in the ER, but we were back less than six hours later because after the reduction, she lost all feeling in her two little fingers. We waited in triage for hours. During that time, I gave her Children’s Tylenol from my purse. When we were called back, I let the nurse know I had given her Tylenol in the waiting room.

Guess what they charged me for when the bill came? Yea, they actually charged me $10 or me to administer my own Tylenol purchased from a drug store.

44

space_antlers t1_iuk3s70 wrote

What did they say when you disputed that?

19

CentiPetra t1_iuk5dv0 wrote

They said basically, "well we don't have a code for when a patient administers their own meds. We just have a general code. But I'll remove it from the bill."

27

JannaNYC t1_iujvwvg wrote

Let me get this straight: The wife / medical biller got the bill, saw a procedure that was never performed, and it took a year for them to remove it?

So she wasn't "able to knock thousands off the bill", she found an error and asked them to correct it?

30

stillragin t1_iujmvky wrote

After trying good RX and not getting a decent discount I was just told to go do more coupon hunting for my meds. That are about $300

I've been without them for weeks now.

Fun times.

28

Meatloaf_Smeatloaf t1_iujnokq wrote

Did you search with the manufacturer directly? They often have their own coupon plans and if you don't find that, search the manufacturer and income assistance or something along those lines, they might have a general way to help.

There's also Mark Cuban's http://costplusdrugs.com though they're limited in what they offer.

Sam's Club, Costco, and Walmart can have cheaper prices and some places are cheaper if you pay cash instead of insurance

This website might help: https://medicineassistancetool.org/

39

jr01245 t1_iujpjlp wrote

Try googling the med name and payment assistance or payment card. It gets my specialty med from 1500 to 5 per month and most companies have something similar on other lines of meds.

10

Matrix17 t1_iuk6uzv wrote

It's a nice thing, but their salary limits to quality are horseshit. It's straight across the board in the US. So if the cutoff is $70k and you live in the Bay Area where salaries are generally higher, you're fucked because you "make too much" even though that salary is barely enough to get by there

But live in the middle of nowhere Alabama? You're good even if you make below that and save a shit ton of money because the cost of living is low

10

IAm-The-Lawn t1_iuk7dsh wrote

Look at Patient Assistance Programs for your medications. Each one is named something a little different, depending on the company.

4

upstateduck t1_iujrfp0 wrote

OptumRX has good pricing for my meds. Worth a look

2

Unsteady_Tempo t1_iuk7jew wrote

There should be ongoing audits, ratings, and fines for every hospital and private practice. The rating would need to be posted publicly like restaurant inspection scores.

22

RCrumbDeviant t1_iuk21kf wrote

Relevant anecdote: as a minor(15) I was at an outdoor concert and got stomped on, collapsed onto someone and got involuntarily crowdsurfed/pushed forward and over the rails separating crowd and band. Lying there stunned, some paramedics grabbed me, put me in an ambulance and took me to a hospital. I kept telling them I needed to go back, but they insisted they had to take me. I get to the ER, and I sit there with a guy who has his head cracked open before they take me, X-ray me, and call my mom to come get me.

Fast forward to a $8k bill about a month later. One of the charges on it was for IV services (that weren’t performed) and would have been difficult to perform because I’m so needlephobic I need to be restrained for a blood draw. Let alone my mom picked me up and I had no needle marks or IV.

When she brought out the big guns (that she’s a lawyer and that they essentially kidnapped me) they ended up dropping the cost to $800 which insurance paid. She still will get upset about it if it’s brought up.

21

lacroixluva t1_iujn8su wrote

This is a solid article with a lot of great resources for patients. Thinking I want to save it for future reference even.

20

Budget-Scared t1_iujt0nu wrote

I've tried this on multiple occasions and it has never done anything. They just give me an itemized bill that is equally as crazy but for the same amount.

17

Mapleine t1_iuk3bvq wrote

> However, he thought, who was he to question the hospital’s billing department?

Weird take from a doctor. I get incorrect medical bills constantly.

16

11ej25 OP t1_iuk3mjd wrote

There are many things that I found odd about this article...

7

bikingbrett t1_iujrway wrote

this happened to me when I broke my color bone. I had insurance but with all the fees and the fact I was knocked out and sent the ER, they wanted to charge me 20k, I was able to get it down to 7K. Took me about 5 hours of my time total and about a week and a half of back and forth.

9

chevymonza t1_iuk0sv3 wrote

Infuriating to think that ERs can charge you the full amount because the doctor doesn't take your insurance.

7

DiomedesAuRa t1_iuk3bk5 wrote

This is what I always say, have your kids double major: whatever career path & medical billing.

5

IndexBot t1_iuk8nh1 wrote

Due to the number of rule-breaking comments this post was receiving, especially low-quality and off-topic comments, the moderation team has locked the post from future comments. This post broke no rules and received a number of helpful and on-topic responses initially, but it unfortunately became the target of many unhelpful comments.

1

Silverbenji t1_iujzj3e wrote

Wait. Did she used to be a media analyst that was told a few years ago to learn coding?

−3