Institutional Doctors: Show me the UB!

[legion]

I had surgery the middle of March to remove a cyst. I have an HMO and I paid my $250 copay before the surgery. I followed all of the plan rules. I went to primary car physician that referred me to a specialist. The specialist got pre-approval for the surgery. The surgery should have been fully covered.

Last Friday I got a bill in the mail for $1,349.23 for my surgery. I called the hospital on Monday (5/4) and they told me that the charges were under review from the insurer, ignore the bill.

Yesterday, I got a sternly worded letter from the hospital advising me to pay $1,349.23 immediately. I called the hospital again today (5/8). I was told that on 5/1 the insurance company rejected $1,349.23 of the bill and therefore I owe it.

Hospital: "They reimbursed us at the ER rate, not the outpatient rate, and took some of their money back."

This is kind of funny in itself, because the hospital and HMO are part of the same company.

Me: "So you incorrectly billed the HMO?"

Hospital: "No, they just reimbursed us at that rate."

Me: "You have negotiated rates with the HMO. How does them overpaying you lead to a $1350 discrepency?"

Hospital: "I'm not sure. You'll have to take that up with your insurer."

Me: "I'm not supposed to be liable for a pre-approved outpatient surgery beyond my copay. Either you billed the HMO too much or they reimbursed too little. Can you send me a copy of the CMS-1500 that you sent the HMO?"

Hospital: "The CMS-1500 is a professional bill..."

Me (interupting): "UB, I meant to say UB. I want to see a copy of it so I can go through the bill line by line with the HMO and figure out how they arrived at not owing $1,349.23."

Hospital: "Why would you want to see the UB? That's what we send to the insurer. We can send you a detailed billing statement."

Me: "Does that include the CPTs, HCPCS, NDCs, and ICDs?"

Hospital: "No, but why would you need to see..."

Me (interupting again): "I want to see what the HMO saw so that I can go through it line by line and figure out how they arrived at a deficit of $1,349.23. Then I can determine who made the mistake and take it up with that party. How can I be expected to try to diagnose a problem if I am not looking at EXACTLY the same thing both you and the HMO saw?"

Hospital: "I don't know why you need to see the UB. We don't send that to patients... (Long pause.) Well, this doesn't make any sense. I don't know how they got $1,349.23. I'll call the HMO and see if I can sort this out."

Me: "Okay."

I hang up. She calls back about 20 minutes later and tells me that the HMO originally over-reimbursed the hospital by about $100, but instead of taking back $100, they took back $1,349.23. She says that the HMO has cut them another check, and I shouldn't be liable for anything more.

Here's my question: why the run-around in seeing the actual bill that the hospital sent the HMO. Why does the hospital produce three versions of a bill? The UB for the insurer, a very high-level bill for the patient that is so vague it is meaningless, and a slightly more detailed version for the patient that still doesn't tell the whole story. Do I, as a patient have a legal right to see the UB?

[jyl]

Don't know. But I learned recently that billing and claims and other insurance paperwork comprise 20% of American health care costs.

[Zeke]

I read this 3 times. I don't see an explanation of "UB" which is normal before using an acronym. What is it?

[red-beard]

Gibberish

[legion]

The UB92 is the claim form hospitals send insurance companies.

http://www.shepscenter.unc.edu/research_programs/hosp_discharge/links/UB92ClaimForm.pdf

[RWebb]

"why the run-around in seeing the actual bill that the hospital sent the HMO. Why does the hospital produce three versions of a bill? The UB for the insurer, a very high-level bill for the patient that is so vague it is meaningless, and a slightly more detailed version for the patient that still doesn't tell the whole story. Do I, as a patient have a legal right to see the UB?"

'cuz they wanna screw somebody - probably you - that is Y.O.U. - 'cuz you don't got no auditors on staff...

[sammyg2]

My aetna insurance requires a $25 co-pay and covers 90% of doctor visits. That's not that great but I get to go to any doctor who accepts it (most) and it only costs me $62 a month for a family of 4.

I went to my doctor for a silly ear infection. He looks at it for 5 seconds and writes a prescription, end of visit, I end up getting a bill for over $100 described as my portion. I guess they thought I wouldn't notice they were implying that a simple office visit was $1000?

I called up the doctor's office and they told me they farm out their billing to another company, and they gave me the phone number.
To make a long story longer, after a bunch of hassle and phone calls, they dropped the extra charges.
Seems that they automatically add money to the customer's bills who have insurance like mine because most customers automatically pay it. They said it is not illegal, I disagree and let me state and federal government representatives know about it.

I let my doctor know what was going on, and told him that if I get another bill like that he'll not only lose a patient, it'll be all over the internet and I'll send to my buddy who works for the channel 4 news (he's actually my imaginary friend, didn't tell him that).
The doctor assured me that it won't happen again and that he was going to re-evaluate his relationship with that billing service.
Sucks because I really like him as a doctor, just not by the businesses he associates with.

[scottmandue]

Originally Posted by milt

I read this 3 times. I don't see an explanation of "UB" which is normal before using an acronym. What is it?

???

[TechnoViking]

Just don't pay it. What are they going to do, repo the cyst?

[sammyg2]

Originally Posted by Martin Smith

Just don't pay it. What are they going to do, repo the cyst?

They will turn it over to a collection agency, which will bother you to know end. Not to mention mess up your credit rating.