Medical & Hospital Bills & Billing Errors

Understand Your Medical Bill, Codes & Patient Rights

This video explains how medical costs are calculated and paid for by public and private insurance.  Learn more about the path of that bill, how it’s processed, and who pays for what.  Created by Brookings Institution.

Why medical bills in the US are so expensive is a video that shows the history of how medical insurance and billing evolved to become so expensive.

Your Billing Rights Under Federal Law Some patient rights are guaranteed by federal law, such as the right to get a copy of your medical records but many states have additional laws protecting patients, and healthcare facilities often have a patient bill of rights.

How to Read Your Medical Bill – AARP

Understanding Medical Bills

How to Check-up on Your Hospital Bills

Stuck With Big Bills After ER Visit? – how to fight back when your insurance company doesn’t think you should have gone to the emergency room – ConsumerReports.org

How to Read Your Medical Bill – Understanding CPT codes can help you avoid inaccurate charges AARP

Find A Code – find what you want to know about a medical code. Just enter a code or keyword.

Coding – Everything about physician billing and coding.

What should your medical treatment cost?  Healthcare Blue Book is a free consumer guide to help you determine fair prices in your area for healthcare services including surgery, hospital stays, doctor visits, medical tests, and much more.

Admitted to the hospital or just in the hospital for observation? Know when you’re admitted or just in the hospital for observation! Medicare may not pay for the hospital, treatment, and drugs when you’re in the hospital for observation. You may even be admitted overnight and sometime during your stay, the hospital may change your status to “observation”. Federal law now requires hospitals across the country to alert Medicare patients when they are getting observation care and why they were not admitted.

What’s the difference between ICD codes and CPT codes? ICD codes are used by hospitals and CPT codes are used by physicians.

Funny ICD-10 codes

Burn Due to Water-skis on Fire Coffee Mug. Yes, there’s a mug for that and even a cup, glass, soup mug, pitcher, and a teapot!

But what’s the code for a Burn due to jet ski on fire? The ICD-10 Code is V91.07xA. A friend who is a doctor wrote, “There is a whole section of codes dealing with water craft accidents. Many different types of crafts and vehicles have their own codes. Inflatables with and without power. Commercial, passenger, fishing, etc. Sadly, they lump kayaks and canoes together with the same code set.”

The 16 most absurd ICD-10 codes

Top 10 Most Hilarious Codes in ICD-10

20 bizarre new ICD-10 codes

18 Silly ICD-10 Codes

22 Strange ICD-10 Codes You Never Thought You’d Need

And finally the Top 80 Wackiest ICD-10 Codes

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Leaving Against Medical Advice (AMA)

Can a health insurance company deny paying your hospital bill if you “leave AMA (against medical advice)”? No! You will not have to pay the hospital bill just because you left the hospital against medical advice. According to the University of Chicago Medicine, it’s “…a myth, a medical urban legend…”. See the study at the National Institutes of Health.

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Disputing Medical Bill & Hospital Bill Errors – Medical Bill Review Companies

Companies that review medical bills and hospital bills for overcharging errors usually work on a contingency basis, meaning they get paid a percentage of the amount they save you. That percentage can be as high as 50%, so make sure you understand their charges before you have them review your medical bills or hospital bills.  Also, read our tips below.

Insurance Dispute Services – Provided by HealthCareAdvocates.com. If you’ve ever been denied medical coverage or a medical payment, access to a specialist or you’ve been turned down for a medical procedure by your health insurance, you need Healthcare Advocates Insurance Disputes Services. Our team of professionals will work on your behalf to help you get the care you require. And if you’re covered by a PPO, traditional indemnity plan, Medicare, or MediGap, we’ll also be there for you to handle problems of non-payment, being dropped from your health plan, outstanding charges, bills that were incorrectly sent to you, and charges that should never have been made.  As Seen On: Peter Jennings, CNN, Wall Street Journal, NY Times, Forbes.

Synergy Settlement Services – Provides medical billing review and reduction services only for lawyers. Synergy assists personal injury attorneys by interpreting clients’ coded medical bills and assisting in defending your clients’ legal rights regarding their medical liens and debts often saving several hundred percent more than the amount demanded from patients/payers by hospitals and medical practices.

Medical Billing Analysts perform medical bill review and audit services for lawyers to determine total amounts billed, total amounts paid, and reasonable value of care by looking at the Usual, Customary, and Reasonable (UCR) rates for all medical expenses charged by the hospital or medical provider. For proving damages in personal injury cases, Medical Billing Analysts will provide a comprehensive report and is available for trial testimony to justify all medical services billed. Services are billed at $200 per hour for evaluations. The time involved can range from 2 hours to review a hospital bill and more depending upon complexity and number of bills.

Alliance of Claims Assistance Professionals – a national, not-for-profit organization providing assistance with health insurance claims issues to patients and caregivers throughout the U.S.

Medical Billing Advocates of America – Today’s complex medical billing and hospital billing system allows fraud and abuse to go undetected. Studies have shown that as many as 9 out of 10 medical bills and hospital bills contain errors (of course, always overcharging you). Hospital bill errors and doctor bill errors are compounded by the fact that insurance companies are not reimbursing correctly–they just pay the incorrect medical bills unquestioningly, but deny legitimate charges.  

National Health Care Anti-Fraud Association – Founded in 1985 by several private health insurers and federal/state law enforcement officials, the National Health Care Anti-Fraud Association (NHCAA) is a unique, issue-based organization comprising private and public-sector organizations and individuals responsible for the detection, investigation, prosecution, and prevention of health care fraud.

Big Medical Bills 

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TIPS – What To Do About Medical & Hospital Bill Errors & How To Get Treatment

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If your insurance company is denying medical treatment you believe is necessary to save your life or can evoke emotional interest, try calling TV news and radio stations in your area.  Many TV stations have programs that help people with problems that they portray on the news.  The insurance may not want to be featured as denying you needed treatment.

If you have already incurred substantial medical bills which you cannot pay:

Bankruptcy: You could consider requesting a bankruptcy lawyer to either call the hospital and negotiate a substantially reduced fee or to file for bankruptcy.  If you do consider bankruptcy, you may want to consider it only after you have received all medical treatment.

How to Dispute Hospital Bills:

Request both the hospital and your insurance company to audit the hospital and doctor bills.

Demand an itemized bill (you must be given an itemized bill if you request one) and review for the following:

Duplicate billing: Make sure you haven’t been charged twice for the same service, supplies or medications.

Number of days in hospital: Check the dates of your admission and discharge. Most hospitals will charge for your admission day, but not for your day of discharge.  If you were charged for the day of discharge, ask the hospital to waive the charge for that day.  If the hospital charges you for your room/bed on the day of your discharge and charges someone else for the same room/bed on the day of their admission, the hospital will be paid twice for the same day.

Incorrect room charges: If you were in a semi-private room, make sure you’re not being charged for a private room.

Operating Room: It’s not uncommon for hospitals to bill for more operating room time than you actually used. Compare the charge with your anesthesiologist’s records.

Unbundled Charges:  This is when a group of tests is billed individually when they should have been billed together.  Surgical procedures and tests frequently consist of several parts.  For instance, you could have received a cervical MRI and a lumbar MRI.  A hospital or MRI facility can bill $1,200 for each MRI if they were done at different times, however, if they were performed on the same day the total amount that the facility will be paid by an insurance company may be only $1,400 or $1,800 instead of $2,400.  Many times, MRIs will be scheduled on different days, frequently one day after the other, in order to bill at a higher rate.  Do not allow a hospital or MRI facility to charge you the full price if they did this.  An example of a procedure could be where you fractured two fingers and you were charged the full price to set each finger individually, instead of the full price to set one finger and a discounted price for the second finger.

Up Selling:  This occurs when a doctor orders a generic drug that is readily available, but the hospital provides you with a more costly brand name drug without your knowledge or consent and bills you for the more costly medication. Since you are not an expert at determining whether or not a drug use generic and you may not have even been in a mental condition to make that determination; your doctor ordered the generic drug, and it was readily available in the hospital drug store, you are not responsible for the increased charge.

Fraudulent Coding often called Up Coding: Hospitals may change the charge for a lower-cost service or medication to one that’s more costly. For instance, a doctor may order a generic drug, but the hospital “accidentally” bills the patient for a much more expensive brand-name drug when the generic is actually provided. If done intentionally, this is a fraud.  Where this occurs several times on one bill or occurs with multiple patients, this could constitute intent.

Fraudulent Coding/Weird Charges/Fake Language:  Hospitals may invent confusing language to cheat patients. They use medical-sounding names for everyday items and charge you an astronomical price. For example, an “oral administration fee” is really a charge for the nurse handing you pills. You do not have to pay for that because it is part of the room and board. Other items that have appeared on hospital bills are: “disposable mucous recovery systems” (a box of Kleenex tissues); “Thermal therapy” (a plastic bag filled with ice);  “Gauze collection bag” (a trash bag); and finally, one patient who was given a teddy bear by the hospital and charged for a “cough support device.” Not only is this fraud, but the teddy bear was a gift.

Keystroke error: A computer operator accidentally hits the wrong key on a keyboard which can result in an incorrect charge or a charge for a service you didn’t get.

Canceled work:  You may have been charged for expensive services or tests that your physician ordered and then canceled or for some reason was never rendered.

Assignment: Check to see if the hospital or doctor accepts an assignment of your insurance payment. This means that the hospital or doctor is allowed to bill your medical insurance and to receive payment directly by your insurance company, without a check going to you. This is a good thing. You can find out if the medical provider will accept an assignment by asking your insurance company. When a hospital or doctor accepts an assignment, you are assigning to the hospital or doctor, your right to the reimbursement check from your insurance company. By accepting an assignment, the medical provider is now in your position and has whatever legal rights you had to collect the payment and no more. When accepting an assignment, a hospital or doctor may not legally seek any payment from you. This means that if the medical provider bills your insurance company for $3,682 and you were only entitled to be reimbursed $1,136, the medical provider must accept this amount and you are not responsible for the remainder of the bill.

Why do hospitals and doctors accept assignments of claims? Because when the check goes to the patient, many patients keep the money which requires the hospital or doctor to sue the patient. Accepting an assignment allows the medical provider to know that they will be paid and to avoid the costs of litigation if the medical provider must sue the patient to recover payment for services rendered.

See what you can do if you can’t afford medical treatment

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Health Insurance Claim Denials and Appeals

How to appeal an insurance company decision – You have a legal right to appeal if your health insurance company refuses or denies to pay a claim or terminates your coverage. There are two ways to appeal a health plan decision (See this link at HealthCare.gov for details):

  1. Internal appeal: If your claim is denied or your health insurance coverage canceled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
  2. External review: You have the right to take your appeal to an independent third party for review. This is called an external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.

Tips For Appealing A Denied Health Insurance Claim

Health Care & Insurance Forum

Find sample health insurance appeal letters on Google

Free Help With Health Insurance Denials

Call your state senator for help. Your local legislators are very eager to help you because they need your vote. When a health insurance company gets a call from your state legislator, they want to comply and show the legislator they’re doing the right thing.

Call a local TV news station. Many TV news stations have a consumer complaint show that can often help you. They help many people whose stories never made it on air. Even if your story is not interesting enough for TV, they are successful in solving problems because when they call a company saying, “This is XYZ News”, the company usually complies because they don’t want to be on TV.

Cancer.org provides useful information about where to find help with a health insurance appeal.

Even Doctors Need To Be a Lawyer To Fight Health Insurance Denials!

Everyone, even your doctor, needs to know how to be a lawyer when dealing with insurance companies. Unfortunately, it’s no easier when dealing with health insurance companies.

Tip: Your doctor should write a report to the health insurance company stating why the treatment is needed for a medical reason that is covered by your health insurance. This is where it is helpful to know how to write like a lawyer. Your doctor needs to take the time to think about what the insurance company wants to approve the claim and how to explain it in a way that will satisfy the insurance company.

For instance, if the procedure is normally used for cosmetic reasons, your doctor must provide the specific reasons WHY the treatment is needed for a medical reason and HOW the doctor knows this (how the doctor came to that conclusion). Of the Who, What, When, Where How, and Why questions, it is sometimes the WHY and always the HOW questions I see doctors omit from reports. It’s not easy, even many lawyers aren’t good at answering why and how, and is the reason I have won many motions in court.

Kevin Pho, M.D. (KevinMD.com) explains two excellent lawyer-like tips to doctors in this video what they should record in their medical records and say to insurance companies.

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Disputing Medical Liens Against Your Personal Injury Case

If you were injured in an accident and are being represented by a personal injury lawyer, you may have various government agencies and insurance companies seeking to be reimbursed from your personal injury case for the money they paid for your medical treatment. To make sure they get paid back, government agencies and insurance companies may place a lien on your personal injury case.

​Possible Liens:

  • ERISA
  • Medicare 
  • Medicaid 
  • Private Insurance Company liens
  • APIP No-Fault Subrogation claims (not a lien)
  • Doctor’s liens
  • Settlement Funding liens.

Many personal injury lawyers just pay these liens in full without disputing them. If your personal injury lawyer wants to pay one or more of your liens in full, you can ask your personal injury lawyer to engage a lien reduction company to dispute and reduce your liens or you can contact one of these lien reduction firms which will work with your lawyer to help maximize the amount you get from your personal injury case:

Precision Resolution, LLC 

Synergy Settlement Services

Learn how to dispute and fight ERISA liens from a former attorney at Rawlings