With many consumers paying more out of pocket for health-care costs, the last thing we need is a doctor or hospital charging us for procedures that weren’t performed or exaggerating the cost of those that were.
Consumers need to review their medical bills carefully. My own recent visit to the doctor’s office is an illustration of the type of overcharge you might catch.
I recently visited my primary-care physician to remove a shard of glass embedded in my foot. Though it was easily accessible with a pair tweezers, I thought the doctor take care of it. Besides, it was painful.
It didn’t turn out as I had expected. Instead of removing the shard himself, the doctor immediately sent me to one of his medical group’s podiatrists. Confirming it was glass, the podiatrist applied topical pain killer, pulled out the shard with a pliers-like tool, and finished up with some antiseptic and a Band-Aid. He probably spent about as much time as it’s taken you to read this far. Then he left.
I was astounded weeks later when I got the bill: $534 (reduced to $363 under the doctor’s negotiated insurance rate). The charge to me personally was $238.
When I complained about such a high bill for such a minor procedure, an insurance company representative explained what had happened: The podiatrist billed for the visit using two industry-standard current procedural terminology (CPT) codes, neither of which appeared on the statements I got from the medical group or insurance company. One was for a new-patient evaluation lasting 20 minutes or more. The other was for removal of a foreign object using “incision,” in other words, surgery.
What 20 minutes? What incision?
I notified the group’s medical director. After investigating, he concluded that I should have been billed only for a brief office visit. The revised charge? According to my insurer, $77. That’s $286 less than the original bill.
So was the original charge a result of clerical blunders by the doctor or his billing department? Or was it medical “upcoding,” a fraudulent attempt to exaggerate procedures to inflate the bill? The medical director told me he was directing his staff to sample 12 months of the podiatrist’s bills. If he found a problem, he assured me, he’d fix it across the entire medical group. I don't know the outcome, and I probably never will.
What should you do in the event you suspect your doctor is overcharging?
When you get an explanation of benefits or Medicare summary notice for a doctor or hospital visit, don’t blindly accept it, especially if you’re being billed for part or all the cost. Find out exactly what the charges are for. If the CPT codes aren’t listed—and they probably aren’t—call the doctor’s office and find out which code or codes were used. Your insurer may help you find out, too. You likely can determine what the codes mean by searching “CPT” and the code number on the Web.
If something’s amiss and the provider won’t correct it, complain to your insurer’s fraud department or the Medicare company that paid the claim. Check your explanation of benefits or Medicare summary notice for contact information. Consumer Reports Health offers other ideas here for making your health insurance work for you
Have you been a victim of a medical billing error? Tell us your story.—Anthony Giorgianni