One of my family members recently had an endoscopy procedure. It was recommended at this stage of life and was purely preventative. According to our UHC insurance that procedure is covered at 100% when its a preventative screening. After the test the physician met with us and told us the results were "unremarkable".
Note my surprise, then, when I received and EOB for the procedure asking me for $800 as my portion of the expense. We called UHC who explained that physician's office had coded the procedure as "General Illness" and so our plan would only pay 80% after a $500 deductible. I tried to explain back to them that the procedure was covered at 100%, to which they replied that as long as the bill was coded anything other than "Preventative" there would be a deductible and co-insurance.
Next I went to the physician's practice at Vanderbilt Clinic. After three phone calls over four weeks and ever-elevated blood pressure, I took an unusual step. I jointly emailed our UHC rep, the physician, and the VUMC billing dept rep explaining that someone had made a mistake; either the physician was wrong when he told us that he found nothing, the coding was incorrect when an unremarkable test result was coded as an "illness", the billing was incorrect if a preventative screening was billed as an illness, or the claims processing was incorrect if a co-pay and deductible was applied to a preventative service.
Well, none of them were amused and I did have to make a phone call to Vanderbilt Patience Advocacy. Eventually, on 9/23 (8 weeks after the service date) the physician's bill was reprocessed and paid at 100%.
So all was well. Until it wasn't.
Two weeks ago I received a $297 bill for the hospital's portion of the billing for this same procedure. My wife called while I was at work and Vanderbilt Patient Billing explained to her that this bill had already been reprocessed and that UHC would only pay 80%. We did indeed owe this. Two days later, this last Saturday, I received a final notice from Vanderbilt on this same balance.
Monday morning I called Patient Billing. I found that their customer service calls are taken by their accounting staff and I had a 40 minute conversation with a lady determined to tell me I was going to pay the bill. One supervisor conversation later and this bill is now in coding for review, which is what has to happen before it can be recoded and billed properly.
This long narrative is meant to make these points.
1. Vanderbilt's medical coding and billing has stumbled in recent months. I'm not sure what's wrong over there, but you should look at your bills and make sure that what they're charging you squares with what you understand your benefits to be.
2. You should question any charge to UHC and to your provider that is for more than you think you owe.
3. Make sure and get a printout of your scheduled benefits off myuhc.com or from HR, as the first time we asked UHC about our benefit they misquoted it until we faxed them our benefit schedule.
4. Keep your cool. The people who take these calls are accustomed to yelling and screaming and you make yourself refrigerator noise when you do. Get your facts together and beat them with kindness, calm, reason, and superior facts.
5. Medical billing staffs are not terribly well trained or well qualified. This profession is like Education and Human Resources. Anybody can get into the field so while you can have professionals of high quality and integrity you can also have under performers make a career out of making mistakes. Don't ever assume that your bills are coded correctly.
6. Ask HR. Before you let any of this make you crazy, come see us. We deal with these types of issues all the time.
Whenever I deal with my own insurance I get really concerned for everyone else. I've been administering benefits for 25 years, I know bad work when I see it, and I'm not afraid to call it out. If I have this much trouble, what does everyone else do? My concern is that you pay it and move on.
Before you pay something you don't believe you owe (because the providers and insurers will certainly let you!), come see us.