What to do when your doctor overcharges

Costly mistakes happen all the time. Here's how to fix your bill.

Published: June 26, 2015 09:15 AM

As medical director for Consumer Reports, I help other people deal with confusing medical bills all the time. So when it happened to me, I was ready.

The bill in question: $1,459.90 from an anesthesiologist for my husband’s recent colonoscopy. It took me by surprise because I knew that anesthesia for screening colonoscopies (what he was supposed to have had) is now covered by insurance. Before Jan. 1, 2015, anesthesia coverage was somewhat murky.

I also knew that the Affordable Care Act requires most private insurance plans and Medicare to fully cover many preventive services, including screening colonoscopy, something many doctors don’t know.

That meant we should have had no out-of-pocket costs—no co-payments, co-insurance, or deductibles. (Read more about what all of those terms mean.) In our case, the doctors had coded the colonoscopy incorrectly, one of many mistakes that can cause consumers to receive bigger medical bills than they should. According to the American Medical Association, 7 percent of the medical bills in 2013 had errors. Other groups estimate that the figure is much higher.

Here are the steps we took to correct the problem, and what you can do as well:

Arm yourself with information

Familiarize yourself with what your insurance does and doesn’t cover, and read invoices from your health care providers and the explanation of benefits from your insurer. Make sure that basic information, such as your name, contact information, policy and ID numbers, and dates of service, is correct.

For preventive services, find out which ones should be fully covered. Two common examples: blood pressure screenings for all adults and diet counseling for adults at higher risk of chronic disease. Get a complete list at healthcare.gov/preventive-care-benefits. And be aware that “grandfathered” insurance plans—those that existed before March 23, 2010, and haven’t made significant changes to coverage since then—don’t have to cover preventive tests completely.

Track down the source of the mistake

If you get a surprisingly high bill or one you think should have been covered, contact your insurance company’s customer-service department. Confirm that all of the basic information is correct. If you got a bill for a preventive service such as a cholesterol screening, ask whether it should be covered 100 percent, and if so, why you got a bill. (Also determine whether your insurer falls under the grandfathered rule.)

And last, find out whether your claim was coded correctly by your doctor or his staff; an error can trigger a denial of coverage. In some cases, the diagnostic code or procedure code may be wrong; in others, a critical number may have been omitted.

Ask for and keep copies of test results. When our primary care doctor sent my husband’s results, I could see that the test done was indeed a screening colonoscopy; the gastroenterologist and anesthesiologist had billed for a diagnostic test. Insurance payment rules for the two differ.

As you proceed, write down the name and contact information of those you speak with, along with the date and substance of the conversation. You can also reach out to your state’s department of insurance for help. Use the Consumers Union Health Insurance Complaint Tool to find out where to complain in your state.

Ask for a corrected claim

In most cases, you’ll have to ask your doctor, hospital, or outpatient facility to submit a corrected claim. After noticing our billing error, I called the anesthesiologist and gastro­enterologist to tell them the charges were inaccurate. By the end of the day, each had assured me that he would submit corrections to the insurance company.

Of course, it’s best to clarify coverage beforehand. So the next time you schedule a preventive visit, for example, ask whether it’s eligible for no-cost care. At your appointment, ask the doctor to tell you if the visit changes to diagnostic care or treatment. And be prepared: October will bring a new system of diagnostic codes. Expect the number of billing errors to balloon—until doctors and hospitals adapt.

Orly Avitzur, M.D.

Medical Adviser
Editor's Note:

This article also appeared in the July 2015 issue of Consumer Reports on Health.

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