Why Medical Billing is Broken

Why is Medical Billing so Broken and Confusing?

Understand your medical bills and learn options to fight back when they’re wrong.

A couple with a toddler was told by four doctors to get an expensive genetic test to help diagnose their child. So they did. But insurance denied it. How could a necessary test be denied?

The fact is, this real example that our team was called in to deal with is a common one. We only wish it weren’t so common. Simply put, medical billing is broken and confusing. And there’s no easy fix, without a cohesive framework to detect, catch and ultimately prevent, problems.

Shockingly, it’s been estimated between 40 and 80 percent of medical bills contain errors.

But due to the complicated and complex nature of our healthcare billing system, inaccuracies are hard to spot. And when you do catch a problem, it can be difficult and time-consuming to get in touch with the right contact to help fix it. Patients who suspect wrongful charges can spend weeks, or months playing phone tag and fighting to get billing errors rectified. 

The gap where patients find themselves in the billing cycle calls for a standardized way for patient claims to be paid, an industry standard. The need is clear: sound practices with policies, procedures, and protocols that benefit the patient.

What recourse do you have as a patient? We’ve been auditing medical claims for over 10 years, and we’ve seen it all. Here’s how to stay savvy, understand your medical paperwork, and fight when you suspect a charge is wrong.

Figuring Out the Piles of Paperwork

The average person doesn’t know what to do with the onslaught of medical paperwork they receive in the mail. And they shouldn’t need formal training to decipher the terminology and varying types of statements. 

But 74% of patients say they’re confused by their medical bills and Explanation of Benefits (EOBs), according to an annual report on Trends in Healthcare Payments by InstaMed.

So what is all that paperwork? Sometimes you’re handed a printout at the doctor’s office, sometimes a bill or invoice comes in the mail, and sometimes you receive something called an Explanation of Benefits (EOB). What do you do with all those documents?

Which Bills Do I Owe?

First, let’s take a look at the different terms you may come across. 

  • Claim: Your doctor files a claim to your insurance company, expecting to be paid. Much like you file a claim to your auto insurance company after an accident.

  • EOB: An EOB is the final word on what you as a patient owe (except when it isn’t). Your amount due to the provider is listed as “patient responsibility.” 

  • Invoice, bill, statement: These terms are used interchangeably to describe a bill sent to a patient showing what is owed.  

  • Clinical summary: This is the printout you receive at the doctor’s office showing your symptoms, diagnosis, treatment, and what you discussed during your visit. It’s a good idea to keep track of this to be sure your insurance is billed properly.

How to Spot Errors Like a Pro

Now that you know how to decipher the jargon, what do you do with this information? At HealthLock, here’s where we see the most errors in patients’ bills, and how you can address them. 

Look for red flags in bills. Billing errors are very common. They can occur by front desk staff mis-typing your card information, the billing department submitting the wrong code to insurance, or a computer error adding an extra line item in your invoice. The fact is, a lot of hands touch your file, and there’s ample room for error (whether intentional or not) every step of the way.

How can you identify a red flag? Question any bill that’s above your copay. Unless you know your copay, deductible, coinsurance, and other aspects of your policy like the back of your hand (which can be difficult for even medical professionals to understand), just go ahead and question it. It’s your right as a consumer to know.

Be wary when you’re asked to pay up front. If you’re asked to pay any fees above your copay at the time of service, it’s a problem. Providers are simply not allowed to collect payment above a patient’s copay before submitting a claim. The same goes for any bills that come in the mail before insurance processes your claim. 

Always wait to pay any bills from your doctor, hospital, or other provider until after you’ve received your EOB, which means your insurance has been billed and has paid their portion.

How to fight: If you’re in-network with a doctor’s office and you’re asked to pay more than your copay at the time of your visit, just step to the side and state that you’re calling your insurance carrier now to see if you need to pay. It always pays to check.

Check every bill. Compare your EOB to each invoice and as soon as you notice an error, address it. 

Called the insurance carrier and got the runaround? Don’t back down. And if you suspect fraud, you’ll find a number on your insurer’s website for reporting any suspicions.

How a Personal Healthcare Advisor Can Help You

The struggle is real. And frustrating. A Personal Healthcare Advisor (PHA) disputes medical billing inconsistencies, advocating on your behalf to get your bills corrected and reduced. An experienced PHA has years in the industry, knows right off where mistakes happen, and has the tools and know-how to fight for you. They’re educated on each state’s laws and each insurance carrier’s processes. With a PHA on your side, you know that someone is working on your behalf, giving you back valuable time, peace of mind and in many cases, considerable savings.

And by the way, we got a favorable outcome for the couple with the toddler. It took 8 months and going through multiple levels of appeal when HealthLock finally took the case to the state. PHA Jessie assembled documentation from four doctors, medical journal articles, and research about the patient’s condition. The result? The state demanded that the insurance provider pays for genetic testing. The couple was ecstatic.

Why not get started today with a free audit of your medical bills? Automated Alerts will warn you of suspicious charges worth pursuing. You can choose to fix them on your own or sign up for HealthLock Premium to have a PHA investigate and fight on your behalf.

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