All Medical Bills Need to be Reviewed.

Posted on September 20, 2022

Healthcare is a business. The business that hires doctors, hospitalists, nurses, technicians, administrators, billing clerks, housekeeper’s, food service staff and others. It is the physicians and midlevel practitioner’s (nurse practitioners and physician assistants) that generate revenue for the business. Healthcare’s focus is on the bottom line - administrative costs, insurance premiums and denials. In no other situation or circumstance do we agree to pay for services if we don’t know how

Healthcare is a business. The business that hires doctors, hospitalists, nurses, technicians, administrators, billing clerks, housekeeper’s, food service staff and others. It is the physicians and midlevel practitioner’s (nurse practitioners and physician assistants) that generate revenue for the business. Healthcare’s focus is on the bottom line - administrative costs, insurance premiums and denials.[i]

In no other situation or circumstance do we agree to pay for services if we don’t know how much and for what we’re being charged?

The Consumer Financial Protection Bureau (CFPB) recently (3/1/22) released a report highlighting the complicated and burdensome nature of the medical billing system in the United States. The report reveals that the U.S. healthcare system is supported by a billing, payments, collections, and credit reporting infrastructure where mistakes are common, and where patients often have difficulty getting these errors corrected or resolved.

As of last year, 58% of debts recorded in collections were for a medical bill, according to the Consumer Financial Protection Bureau (CFPB). That's nearly four times as many debts attributable to telecom bills, the next most common form of debt on credit records.

“When it comes to medical bills, Americans are often caught in a doom loop between their medical provider and insurance company,” said CFPB Director Rohit Chopra. “Our credit reporting system is too often used as a tool to coerce and extort patients into paying medical bills they may not even owe.” [ii]

We don’t receive an itemized bill or the have an opportunity to review it for accuracy until weeks, sometimes months following discharge from a hospital or ER. When it finally lands in your mail or inbox, it needs to be scrutinized for good reasons. They are notorious for containing incorrect charges, often the result of balance billing, upcoding or unbundling – all of which may be illegal.

Unless you have specifically asked, the statement you’ve just opened is a summary bill – often 1 to 2 pages. It does not have CPT codes. In order to make sure you haven’t been overcharged; you need to be looking at is an itemized bill. This statement contains CPT codes (the uniform language for coding medical services and procedures). It will be at least 10, 20, sometimes up to 200 pages.

Never Pay Your First Bill

HIPPA (The Health Insurance Portability and Accountability Act of 1996), requires all providers give patients full access to their medical records – meaning you have a legal right to an itemized bill. Providers who don’t full comply with this will face severe fines and penalties.

Call the hospital’s billing or patient accounts department and ask for an itemized bill with CPT codes. If you get excuses as to why this information cannot be provided to you, ask to speak to a supervisor and inform that you are making a request for your “complete itemized bill with CPT codes per HIPPA medical records access requirements.”

If you have continued difficulty, put the request for an itemized bill with CPT codes in writing. In the letter, provide a deadline with a date to respond by and let them know you will file a HIPAA violation complaint with the Office of Civil Rights (ocrportal.hhs.gov) if you haven’t received it.

If you have insurance, never pay any bill before you receive the Explanation of Benefits Source: Crush Medical Debt, Virgie Bright Ellington, MD.[iii]

Never, ever agree to a payment plan during the registration or discharge process in the Emergency Room or any other area or hospital department, when asked to do so.

Prior Authorization Caution. Also known as pre-certification or predetermination, is required by insurance plans for approval before it will cover certain services, treatments, medications or devices.

Be careful. If the physician obtained prior authorization, it does not guarantee payment. The insurance plan’s medical policies may determine the service is not medically necessary for the particular condition that has been ordered.

Best Strategy: Whenever Possible Know Before You Go.

The role of Professional Patient Advocates. As with any number of patient outcomes, independent patient advocates make a difference. We are part of the healthcare ecosystem, providing guidance to patients as they engage with the healthcare system.

Many of us come from medical administration or utilization backgrounds and are knowledgeable about navigating health insurance and negotiating medical debt.

Those of us who have earned certification as a Board-Certified Patient Advocate (BCPA) through the Patient Advocate Certification Board (PACBoard.org) have passed a rigorous certification exam and committed to the BCPA ethical standards and code of responsibility. Our sole focus is the patient with the goal to ensure his/her needs are met and rights protected.

[i] Medical care is the profession. It is the diagnosis, prognosis and treatment of that which ails us. It is the relationship we have with our doctor and specialists. Medical care is also about continual discovery about disease, processes and prevention.
[ii] CFPB Estimates $88 Billion in Medical Bills on Credit Reports | Consumer Financial Protection Bureau (consumerfinance.gov) March 01, 2022.
[iii] Crush Medical Debt, Virgie Bright Ellington, MD, 2022., p.6.