The American health care system is either the finest in the world or a hopeless morass of waste depending on who you talk to and their party affiliation. One thing that is absolute truth about our system is that it's complicated, and one of the root causes of that complexity is the interface between medical coders, medical provider billing, and your insurance plan. I'm near the end of a medical coding/billing/insurance problem that I've been working since July. The facts of this case (which I have permission to share) should help you understand why it's important to know your benefits, watch your bills, question everything, and use your HR department if necessary.
In July we had a dependent on the plan who was referred by her primary care physician for a colonoscopy. The patient here had no symptoms or problems but had reached the age when that procedure is recommended. The colonoscopy was performed later that month and the results were clear except for a mild case of diverticulosis, which requires no treatment. The patient was told to come back in 10 years to repeat the procedure. The UHC benefit for a precautionary endoscopy is 100%.
So imagine the employee's surprise when they received a nearly $300 bill for their 20% of this procedure. They asked for our intervention and I called UHC, who replied that the medical coding had been a "diagnosis" code, meaning in coding lingo that the procedure had been done because of a diagnosis, not as a precautionary wellness measure. We contacted the doctor's office, who said the medical facility's billing department did the coding. We contacted the medical coding unit who said that was the doctor's notes and so couldn't be changed.
I did something here that I've never done; I emailed the UHC rep, doctor, his nurse, and the facility billing department and said, in essence, "Who made the mistake?" If the coding is right then the doctor is wrong; if the doctor is right then the coding, billing, and insurance are all wrong. I don't anticipate getting a Christmas card from any of them, but finally a patient representative from the hospital called and said that the doctor's notes would be sent through for re-coding and re-billing.
About four months later the employee gets yet another bill for the co-pay. We speak with the medical facility's accounting department and UHC (who was wonderful in this instance), and UHC sent them what they said was their third verification that the patient owed zero balance. I spoke with the Accounting the department with assurance that all was well. Last month the patient received another bill for the co-pay, so this time we faxed the Explanation of Benefits showing no patient responsibility to the Accounting unit.
Over the weekend the employee received another bill for the same amount. Today I called and asked to speak to an Accounting supervisor, only to find that the accounting clerk who received my fax didn't forward it to the Adjustment Office for re-billing, and assures me all will be corrected this month.
At the heart of the problem is the complexity of the tasks vs. the ability of those performing them. Medical Coding is a semi-skilled vocation that really should be a highly skilled vocation. As a field it is trying to professionalize but has a long way to go. Unfortunately, how providers bill is based on this coding , and there's a lot of bad coding being done. Similarly, hospital and independent physician billing is complex and about half of the people doing it aren't up to the job. Finally, you have the insurance carriers who will readily question a strange bill if it costs them more money, but who are all too happy to rely on the coding and billing if it costs them less. In this case, as I said, UHC was very helpful.
Moral of the story? Questions your bills. In this case the employee knew that their plan paid 100% of preventative endoscopy procedures or they would be $300 poorer today.
If you don't like the answer you get, come see your HR department. We can either explain to you what your owe and why, or help you push back on bad coding and billing. Until patients and health plans become active, noisy and even a little belligerent we'll be the little guy victims in a complex system that favors the institutions who designed it.