It’s no secret that the for-profit nature of the American Healthcare Industry leaves many feeling like they are seen as a Customer and not a Patient. To make matters worse, much like the convoluted Legalese used by Lawyers to tip the odds in their favor, Medical billing has become a tool to make providers more money and keep Patients from asking about it. The rise in Deductible amounts has left even those Americans with good health Insurance wondering how they are going to pay for procedures that should be simple and cheap. While there are cases of Hospitals inflating their prices for the sake of profit, there are other instances where the surprise bill was the result of nothing more than an error by an employee in the Billing department. In this article, I will outline some common Billing & Coding mistakes made by Providers and how to spot them. For the purpose of this research, I am coming from the Providers point of view to give you an understanding of what they look for so you can too.

Unbundling

The Office of Inspector General (OIG) defines unbundling as “billing for each component of the service instead of billing or using an all-inclusive code” (65 F.R. No. 194, 59434, 59439) and when a “billing entity uses separate billing codes for services that have an aggregate billing code” (65 F.R. No. 243, 70138, 70142). To the untrained Patient, this can be one of the hardest errors to spot considering even trained Medical Coders can often be confused about when to Bundle and when not to.

The most important aspect of bundling is the idea that Physicians are paid in a single sum instead of tracking multiple, minute charges. Additionally, the push for bundled services means that it is in the best interest of the Physician to seek out the most effective (efficient) solutions.

Upcoding

Upcoding is the most well-known Medical Billing error for the average Patient and Billing Department Employee. Upcoding is the charge for a service that was either more extensive than the actual procedure, or a procedure that was not done at all. While there are cases of providers purposefully Upcoding their services, it is usually an error brought about by the Diagnosis and Treatment Codes not matching, which we will cover below.

Diagnosis and Treatment Code Mismatch

This is an error that can leave a patient with the highest out of pocket charges. When a Diagnosis Code and a Treatment Code don’t match, especially when the Treatment Code is upcoded to a treatment beyond the scope of the Diagnosis, there is a good chance that the Patient’s insurance company will deny the claim and leave the patient responsible for the additional costs. When you are checking your bill and reviewing it with your provider, ensure that you request the Provider double checks that the Diagnosis and Treatment codes match.

Balance Billing

Balance Billing is the idea that a Provider will charge you for products and services other than your Co-Payments and/or other predetermined Insurance assignments. When this is done to a patient who is not ‘out-of-network’, it is almost always incorrect. This error is most common when you are treated out-of-network, which gives providers more leeway to set the rate at which you will be charged for procedures over your insurance’s coverage.

Now what?

Should you be on the receiving end of a bill that was unexpectedly high, look out for some of these common mistakes and then reach out to you Healthcare Provider and/or Insurance Company. In our article next week, we will cover some tips on how to address incorrect charges with your Physician. This can often be a daunting and intimidating task, but there are steps you can take to ensure you are prepared, with evidence, to argue a charge that just doesn’t seem right.