Ah yes, i got charged for "surgery" too. Called the insurance co, said "no. Xrays, casts, yes. Surgery, no." But they weren't concerned; they said "oh, that's just what they charged it under, it's fine, don't worry." I said "wellllllllll ok i guess..."
The best one was the last time i went to the emergency room; saw only a nurse and a nurse practitioner; then saw later that some random MD whom i had never seen had put in a claim to the insurance co. I waited eagerly for him to try and bill me so i could call his office and say "hell to the no, dude." But he never did. Smart doc.
Insurance fraud is fun, yes?
Gravity works, and the laws of physics are a bitch.
A local doctor is always advertising her specialties on tv. A man I know took his kid there (they take walk ins), and later Tricare called about the bill. He's very medically smart, and was present for the entire pediatrics visit. Tricare was billed for tons of expensive treatments that never happened, and Tricare really went after the doctor's office for it. Many places like this take all kinds of Medicaid, Tricare, and other low paying insurance, and that is a real fraud industry, with phony billings. Medicare and Medicaid patients may not review bills as long as they're paid, and there have been huge Medicare and Medicaid fraud rings busted. I guess medical billing is viewed as a growth and fraud industry by some people.
I don't know how much is intentional, but there are plenty of mistakes in coding. I work with medical billing software, so I have the latest codes on my laptop all the time. When EOBs come in, I look for anything unexpected and double check the codes. Mistakes are pretty common.
A few years ago, my insurance denied a claim for my colonoscopy...which I had before age 50 because my father had colon cancer. The biller coded it as "routine colonoscopy" rather than "colonoscopy, high risk", which would have been paid before age 50. Easy enough to ask them to resubmit the claim properly, but if someone isn't able to check for miscodings, they might be getting overbilled. I've also seen 5 of some procedure when 3 were really done...typo? Hoping no one will notice? No idea. But, as I have coinsurance I don't let those slip by.
Anyone can get the diagnosis and procedure codes from CMS's web site, though they are not that easy to find things in and they are updated regularly, so you have to make sure you have the current version. I think there are some website that might provide a lookup function.
I fell and hit my head and friends dragged me into the ER (in their car) for a CT scan. That was the only procedure I had- I talked to one doctor who ran a brief neuro exam and sent me home. I then got bills for: blood tests, IV fluids, ultrasound of my heart, bills from two doctors who supposedly spent several hours with me. Insurance was going to pay them without any qualms.
The entire March 4, 2013 Issue of Time magazine is devoted to a Special Report - Why Medical Bills Are Killing Us written by Steven Brill. He spent 7 months researching and writing the piece.
He blames the chargemaster , the internal price list hospitals keep. Elected leaders are not reining in hospitals and health care costs. Brill supports that lowering the Medicare age would help lower costs overall. That Medicare helps keep the prices in check.
He summed it all up that we've created a gameable system and the players are getting rich off it and we've squeezed everyone outside of the system who get stuck with the bills. He says that the obvious issue is that "all the prices are too damn high." There is no control, no overseer. He says that Obamacare will change the rules related to who pays for what but it does nothing about the prices we have to pay.
I kept the issue. I put it in my medical file for reference.
The truth is what you can get other people to believe.
A simple step added to the process (having the patient see what the insurance co. was being billed, and click "approve") would put the brakes on some of this. In my case, I think the specialist's practice is ripping everyone off. There was no hospital involved. I went to see my PCP and he sent me to the x-ray department for x-rays of the wrist. He looked at them, determined that it was broken, and sent me to the specialist the very next day. When I arrived, they had my x-rays with my info. The specialist said that the day-old x-rays were "not acceptable" and then sent me to his x-ray room for the same three shots. His practice billed $114 for the x-rays, $336 for a 15 minute office visit ("Yep, it's broken. Come back in two weeks for another look), $875 for surgery I didn't have, and $395 for a high-tech cast.
I've got a follow-up visit next week, so I will ask him to correct the error. After that, the EOB form has a toll-free number to report fraudulent charges.
For one thing, I have never had an insurance company contact me and ask me bullshit about any issues!
I had a hysterectomy yrs ago, was waking out of the anesthesia and the nurse took one look, down there, and had panic written all over her face. I was rushed back down into surgery I was hemorrhaging. They had to open me up again so 2x the charges for everything. And why - because the doctor said I was taking an aspirin a day (before the surgery) How did he know - it was right there on my chart! which neither he nor anyone else ever told me to stop taking before the surgery! I think the insurance company should have had something to say to him about this. But they didn't care.
It just stinks everywhere with medical issues. And we pay the price, there are no protections for the consumer.
The truth is what you can get other people to believe.
The system is so complicated that it is hard for those of us providing the care to enter all of the correct codes for billing and easy for the crooks to steal from the system. For example, if I see a wheezing child, I am allotted 15-30 minutes to care for him, chart the care, prescribe his meds, and enter the codes for checking his oxygen level, giving a nebulizer medication, using a mask and tubing for the medication, and rechecking him. Some of the codes come uo automatically if I enter a diagnosis of asthma with a moderate exacerbation. If I enter any other words for the diagnosis, I have to look up each code as they don't show up automatically. Sometimes, the wrong codes come up automatically. The system is not efficient.
A simple step added to the process (having the patient see what the insurance co. was being billed, and click "approve") would put the brakes on some of this.
In theory, I agree. In fact, it would only work with patients educated on and paying attention to their health care.
I type medical transcription. The amount of people I type on who have no idea exactly what surgeries they had or what for, even with scars obviously only a few months old, or what meds they were on, or even what their own pre-existing conditions are is staggering.
Just today, I typed an ER report on somebody who was on "a heart med." He didn't know if he had ever had a heart attack or not. He didn't know if he had actually ever had a catheterization or not. His last admission, which he thinks was for "heart stuff" was earlier this year (assuming he got that right). Poor ER doc without records (patient couldn't remember name of other hospital where that admission was) was trying to piece this together.
I do agree that there are lots of errors that slip through. I haven't been hospitalized many times, but every time, we went over the bill with fine-toothed comb, and every time, there were mistakes.