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March 4, 2020

Avoid Patients Discovering Surprise Fees, Wrong Charges and Inappropriately Denied Claims

Written by: Compliance blogger


Most patients are educated and internet “savvy” these days, even our seniors! Satisfaction with the financial aspect of your practice is just as important as the satisfaction with the clinical services provided in order to retain your patient base.

When a patient can’t get answers and your organization is part of a hospital-owned network, it is likely the patient may turn to the Ombudsman or Patient Advocate office. If this doesn’t work, there are consulting firms and Medicare Advocates to help them.

Did you know that the nonprofit Patient Advocate Foundation estimates approximately 50% or half of all medical bills contain incorrect charges, wrongly denied claims or surprise fees? “They may charge you for the wrong service or charge you twice for the same service or say you had an ibuprofen when you didn’t,” says Caitlin Donovan, spokesperson for the organization. Spotting an error can save you thousands of dollars, she adds. “That’s why it’s so important to scrutinize your bill.”

Patients are advised to request an itemized list of charges, especially for a hospital visit and to watch for providers lumping all the charges together in what's called a “summary” bill, with a “total due” at the bottom. Patients are also advised to question a statement that does not include any reference to what primary and/or secondary insurance has paid, giving the impression that they owe more than they actually do.

AARP cautions seniors, “If your bill does not include a detailed list of charges, call the doctor's or hospital's billing office and ask for an itemized invoice. That's the only way to make sure you're being charged just for services you received.” Pat Palmer, cofounder and chief executive officer of Beacon HCI, which helps employers and other health care payers identify billing errors and reduce costs, warns patients to review statements for these most frequent billing mistakes in a 2019 AARP article:

  • Incorrect quantities or duplicate charges.
    If a coder mistakenly adds a 0 to a number, you could be charged for 100 pills instead of 10, potentially adding hundreds of dollars to your invoice. Also, make sure a service or procedure isn’t listed more times than it was performed. Duplicate charges are surprisingly common, Palmer says.

  • A treatment, medication or procedure you didn’t receive
    If you were scheduled for a test or procedure but it was canceled, it could still end up on your bill because no one struck it from your chart.

  • Inflated surgery and recovery times
    Hospitals charge by the minute for operating-room time, so it's a good idea to check that they are billing you only for how long you were there. “You can always ask for your medical record to see what time the surgery actually started and stopped,” Palmer says. The same goes for the time you spent in recovery.

  • Charges for basic supplies
    Patients sometimes discover fees for gloves, gowns or other routine items listed separately on their bill. Brown says one claim Medliminal reviewed “charged for a mucus-recovery system, which ended up being a box of tissues.”

  • Room fees
    If the bill includes a hospital stay, check that you were charged for the right kind of room (shared or private) and the right number of days. If you were formally admitted after midnight, make sure your charges start on that day. Also, most insurance companies don’t allow hospitals to charge room fees for the day you’re discharged.

  • Be on the lookout, too, for billing irregularities that could be signs of fraud
    These can include upcoding (listing the CPT code for a more expensive procedure or service than was performed) and unbundling (charging individually for related services typically billed under a single code — for example, incision and stitching for a surgery). If you suspect billing fraud, contact your insurer's anti-fraud office.

It is important to make sure that your office is accurately documenting, coding and billing for clinical services to avoid these types of errors. When codes are incorrect, a claim may be denied and a procedure that was previously authorized may end up not be covered by insurance. Mistakes such as these can cause great financial stress and dissatisfaction with your patients when they are unexpectedly responsible for paying out of pocket. In addition, there may be legal and financial consequences for the practice.

To avoid the pitfalls of incorrect charges, wrongly denied claims and surprise fees, be sure to stay up-to-date on annual coding changes, coding guidelines and keep detailed patient records. We offer several courses to help in these efforts. For instance, you could register for our Appeals Management Course and become a Certified Outpatient Clinical Appeals Specialist (COCAS).


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