Hospital billing mistakes are costing you

LEE COUNTY, Fla. – An exclusive WINK News Call for Action investigation uncovered hospital billing mistakes are more common than you would think and it is costing you money.

When a patient goes to the hospital, the physician is supposed to fill out a form explaining why the patient was seen and the treatment received. During that the process, the doctor puts in a specific code which is forwarded to the billing department. However, Sheri Samotin, a medical billing advocate, said often the bills are improperly coded.

“There are basically two kinds of codes. There’s the codes that code what they did to you, those are called procedure codes so like an established office visit of high complexity has a particular code. Then there’s diagnosis codes, and those are the codes that say here’s what was wrong with you or not wrong with you,” Samotin explained. “The staff are simply just not up-to-date or up to speed, or they’re overwhelmed by the volume and so they kind of fall into a routine of coding things in a particular way. It may not be a deliberate mistake that they’re trying to what’s called up-code.”

However, those mistakes often result in higher costs to the patient.

“I’m dealing with it right now, with a lab charge. My doctor drew blood, sent the blood off to the lab…I got the explanation of benefits from my insurance company. It showed that they paid all but one of the codes. The reason for denial right on the explanation of benefits was that the particular diagnosis is one that’s not covered by insurance…It was a diagnosis that was related to infertility treatment, and in fact the reason these particular labs were drawn is for perimenopausal symptoms, hot flashes and so on…It was a coding error that occurred somewhere along the line, and as a result the insurance company denied it and the lab is billing me.”

Samotin gave another example, where a client was charged for a pap smear but the patient was a man. WINK News Call for Action found often the mistakes are not that obvious.

John Kelly lives part-time in Southwest Florida. Last year he went to the doctor for an annual physical, which according to his insurance provider should not cost him a co-pay. At the same time, he had lab work done, which was also covered through his insurance. A month later, Kelly said Lee Memorial Health Center called him saying he owed $58.16 for his appointment.

“I didn’t challenge it. I actually paid it over the phone by credit card at that point,” Kelly said. “Shortly there after I started receiving additional bills for laboratory work.”

The additional bills were for $200, all for lab work that should have been covered. Kelly called his insurance company, who told him the physician’s office had made a mistake on his bill.

“I was informed that the code Lee Memorial was using was for an office visit, not an annual visit. To me it seemed like semantics, but apparently in the medical billing field they’re very specific with the codes they use.”

Kelly said he spent countless hours on the phone and visiting the billing department in-person to try and rectify the situation.

“I got bounced from person to person. Initially it was just we go by what the doctor writes and that’s all there is to it. I started writing correspondence to them and I received nothing in return, absolutely nothing…This continued through the summer. I had made correspondence through the Attorney General’s office.”

Eight months later, Kelly said he received a voice mail that stated the hospital had reimbursed him the $58.16 he paid for the actual visit and they zeroed his account with the lab work charges. The Department of Agriculture also responded to Kelly saying they had “attempted to mediate your complaint against the business. Unfortunately, the business has refused to cooperate.”

In the meantime, Kelly called WINK News Call for Action. We contacted Lee Memorial Health System to ask about the reimbursement. Mary Briggs, a spokesperson for the hospital sent the below response.

“We make every effort to bill correctly the first time, but on occasion errors occur. Upon review we determined we made a mistake in coding. It appears the annual physical was documented as an office visit, which caused the labs to be incorrectly coded as well. Mr. Kelly’s account has been credited for the charge. We sincerely apologize for this error and the inconvenience it has caused.”

Briggs also said they had no record the Department of Agriculture attempted to contact them.

Samotin said once a bill is improperly coded it is a lengthy process to get reimbursement. In her case, it has been six months and the hospital has not fixed the coding on her bill.

“And that’s for a dinky little claim, where frankly it just shouldn’t be this hard,” Samotin said.

WINK News Call for Action uncovered the mistakes are costing more than just patients. In a report released by the Office of Inspector General (OIG) last year, it found Medicare inappropriately paid $6.7 billion for claims on evaluation and management services in 2010. Evaluation and management (E/M) services include visits where a physician or non-physician practitioner sees a patient to assess and manage a beneficiary’s health. The OIG made three recommendations to the Centers for Medicare and Medicaid Services (CMS) including educating physicians on coding, having contractors review high-coding physicians’ bills and following up on claims that were paid in error.

WINK News Call for Action contacted CMS to ask what has been done since the report was released nearly nine months ago.

A spokesperson said, “While we did not agree with all of the OIG recommendations CMS is working to ensure that physicians and health care providers appropriately bill for E&M services. Some providers have sicker patients, thus are more likely to bill at E&M coding levels that carry higher payments. Every day we work with providers to make patient care the priority, and at the same time ensure they use E&M codes that reflect the level of service provided.”

Call for Action Reporter Lindsey Sablan asked if CMS had recouped any of the $6.7 billion inappropriately paid. CMS responded saying, “that was not a formal recommendation by the OIG.”

They did say they have posted education material on coding guidelines, which can be found here.

Samotin said the most important thing you can do as a patient is to read your explanation of benefits sent by your insurance company. If a claim was denied that you think insurance should have covered, find out why. Also, before you even make the appointment make sure to ask that the doctor you are seeing is in-network. Samotin said when you arrive at your appointment that day, ask the receptionist to again confirm your doctor is in-network.