Two Sets of Hands Filling Out Paperwork


Charles Kennedy Sept. 8, 2015

As we age our medical expenses become bigger as our illnesses become more serious and difficult to treat. We begin dealing with huge expenses for skilled nursing care due to advanced Alzheimer’s Disease, Parkinson’s, various forms of dementia or surgical expenses involved with cancer, heart disease or the results of injury incurred in a fall.

Before getting to legal aspects of medical bills in my next posting I found a very good article at a blog called “The Patient’s Advocate” about how to limit the likelihood of overpayment.  

Mr. Matoren’s main point is to let your insurance company deal with the claim before making any payment. The insurance company has greater expertise at reviewing for duplicated charges, overbilling for a service and more leverage to force a medical provider to reduce the bill to the contractual rates negotiated by the insurance company.

Various studies have found that more than half of all hospital bills contain errors and overcharges. Sometimes it pays to hire a professional auditor. Many of the people providing this service are nurses who are able to understand the terminology and the records required to support a charge on the invoice. There are over 456 codes used to bill for services through Medicare. Private insurance can be even more complicated. 

Some providers routinely “upcharge” a medical service. This is billing for a more complicated and expensive service than the service provided. The federal government has more than tripled the number of criminal prosecutions for Medicare and Medicaid fraud since President Obama took office. Typically these prosecutions are against care providers such medical device vendors, doctors, nursing homes and criminals submitting fraudulent billings based on identity theft.

A recent study by the Centers for Medicare and Medicaid Services (CMS) found extreme variability in the price charged for various medical services at hospitals in the United States. Not only do the prices vary based on where you live, but between various hospitals in the same city. Prices frequently varied by tens of thousands of dollars. The study is reported in the New York Times, May 8, 2013. Our system puts cash buyers of medical services at a disadvantage. This may be the only “market” where this is true.  Do not be bashful about trying to negotiate a medical fee. Just be aware that the bigger the institution the less freedom a front line employee has to negotiate.

In addition, when scheduling a surgery require the surgeon to use an “in-network” anesthesiologist, and if you are private paying get anesthesia included in the negotiated price. Many anesthesiologists refuse to agree to a negotiated price with insurance companies because so few people think to make sure the fee is stated before the surgery.

As the article mentions you also need to make sure the insurance fee is the entire fee.  You want to avoid “balance billing”. Balance billing is when a health care provider accepts your insurance but bills you for the amount not paid by the insurance. This amount is beyond the co-pay or deductible you might have in your insurance policy.

When in a hospital it is important to have someone to act as your advocate ( your medical attorney-in-fact). This person should watch to make sure the staff wash their hands before touching you, that you are the person who is supposed to receive the “service” about to be provided, that you are as comfortable as you can be made under the circumstances and gets an explanation of the care you are receiving and makes notes to follow after you leave the hospital.