I think I'm about to uncover some medical billing fraud.

[Zeke]

I had the usual blood work done in May. All seems well. That is until I get a bill from the lab. $768.75. BC paid $141, the charges were *adjusted* down 66 and a mysterious 'other' adjustment (upcharge) was added. I end up owing 600.

BC denied most of the work done except for some very basic tests like PSA and full count. All work related to thyroid and other organs is denied payment. I've seen this movie before.

What has happened in the past is that a code for a chest x-ray was changed from one indicating that I had some symptoms to one that reflected something like I walked in one day and said, "Let's do an x-ray for no particular reason." That resulted in my owing about 500 dollars. 4 months of calling the doc's office that ordered the x-ray and the billing company and with a letter from the doc got it resolved. I paid nothing just as my plan indicates.

So, what's going on? Well, obviously the labs stand to make a LOT more money it they can NOT get paid by insurance and bill direct. I've asked for all the paperwork from the doc and the billing so I get all the codes.

When I compare them to last year's billing and get some facts, I think I will find out what's up. Attempting to nick me for the full monte using code manipulation. In one call just asking for this information they *offered" me a 'discount' of $240 if I pay now.

Oh, and it's the same folks who did the x-ray scam on me. I think once I get all the paper work this is one for an investigative news reporter to dig up some info.

[Tobra]

There is a difference between fraud and a billing error.

Not saying they did not attempt to defraud you, just saying it may be a simple mistake and not to get too worked up about it, yet. If they are doing the tests for a specific reason, and that diagnosis is not on the lab order, it is going to get denied. What does your EOB from your insurance say?

You are going to see much more of this sort of thing in the future

[recycled sixtie]

Good on you Milt. You don't seem to be taking this thing lying down. So many just pay up or pursue it halfheartedly. Yep a news reporter or even a threat of a lawsuit(without actually hiring a lawyer) may help you and others to combat this white collar crime.

[Zeke]

@Torbra, a simple mistake does not get all the Hemotology, Immumology and Chemistry tests all denied, AFAIK. I can get "of benefits" out of EOB, but I don't know what it is.

Due to the holiday and that fact that many didn't work 2 days this week, phone calls have been difficult. 15 minutes of wait time or more. I will wait until mid week next week to continue with my ins co while waiting for the print out of the break down of my charges. They wouldn't identify the codes over the phone so I have nothing to discuss yet with the doc's office or the ins co.

Yet, I can see the writing on the wall. I wonder what my "discount" is going to be after a couple of registered letters are sent.

[wdfifteen]

Go get 'em Milt. They have made the system so ridiculously complicated errors are virtually guaranteed - and they like it that way.

[LeeH]

Last time I had a physical I got a huge bill from the lab. I had mentioned a couple of things to my doc who ordered lots of extra blood tests. It those extras that were not covered by insurance as part of the physical.

[Tobra]

Like I said, if they did not put the right diagnosis code on it, all that stuff would get denied. For example, if I don't have a diagnosis code that would qualify a radiograph or the correct modifier for a second procedure on the same day, payment is getting denied.

Common misconception that insurance companies are in the business of paying for stuff. Actually, they are in the business of finding ways to not pay for stuff. I had them deny simple pre-op blood work before, after a stern letter they coughed up the dough.

Sorry, EOB/Explanation of Benefits-document that your health insurance is supposed to send you when they get a bill for something.

I think I was the only dumb SOB working on Friday.

[Zeke]

Originally Posted by LeeH

Last time I had a physical I got a huge bill from the lab. I had mentioned a couple of things to my doc who ordered lots of extra blood tests. It those extras that were not covered by insurance as part of the physical.

I get the same tests every year. In fact, I'm only eligible for these tests once a year just like I'm eligible for teeth cleaning 2twice a year and partial dental x-rays once a year. Funny, now that I think about it, I didn't get a script for a chest x-ray this time around. Last year I had about 3 because I had a partially collapsed lung. They were all covered 100%.

I think I know my policy. Ah, and I guess EOB is Explanation of Benefits. Perhaps I need to be the one to explain.

[nynor]

zeke, a little side-tour here, what happened that your lung was partially collapsed? that doesn't sound good....

[Zeke]

Originally Posted by nynor

zeke, a little side-tour here, what happened that your lung was partially collapsed? that doesn't sound good....

In the early winter of 2011-12, I got the flu and coughed so much that I got some bronchitis. It kinda lowered itself into the lung and the bottom lobe got restricted. That's certainly the lay description of a medical problem. I had a lung capacity and breathing test done later in the year and I was 98%.

All of this cost some serious money and it was all covered with the exception of some doc office visit copays which I'm used to.

To mess with me about some blood tests is not very characteristic of my coverage.

[nynor]

Originally Posted by Zeke

In the early winter of 2011-12, I got the flu and coughed so much that I got some bronchitis. It kinda lowered itself into the lung and the bottom lobe got restricted. That's certainly the lay description of a medical problem. I had a lung capacity and breathing test done later in the year and I was 98%.

All of this cost some serious money and it was all covered with the exception of some doc office visit copays which I'm used to.

To mess with me about some blood tests is not very characteristic of my coverage.

ah... atelectasis, bronchiolitis, or pleural effusion and/or edema. not fun. i've recently changed jobs and i audit accounts for the very thing you are posting about. its fun, for me. i hope it all gets sorted quickly.

[wdfifteen]

Originally Posted by Zeke

I think I know my policy. Ah, and I guess EOB is Explanation of Benefits. Perhaps I need to be the one to explain.

EOB is an intentional obfuscation of benefits masquerading as information. I got one a few months ago with 2 line items. One was a string of numbers and the words "immunization," and a price of $37.50. The next line was a string of numbers and the words "immunization," and a price of $37.50. I'm thinking a billing error. Nope. The string of numbers was slightly different. One line was for the cost of the drug and one was for the cost of injecting it. By some bizarre coincidence the cost of the drug and the cost of injecting it were exactly the same! When this apparent mistake was explained to me I asked how often the cost of medication exactly equals the cost of administering it and she said, "often." So the question is, which cost are they just pulling out of their butts? Do they look at the cost of the drug to determine how much it costs them to inject it, or do they look at the cost of injection and decide that happens to be the exact price of the drug?

[nynor]

Originally Posted by wdfifteen

EOB is an intentional obfuscation of benefits masquerading as information. I got one a few months ago with 2 line items. One was a string of numbers and the words "immunization," and a price of $37.50. The next line was a string of numbers and the words "immunization," and a price of $37.50. I'm thinking a billing error. Nope. The string of numbers was slightly different. One line was for the cost of the drug and one was for the cost of injecting it. By some bizarre coincidence the cost of the drug and the cost of injecting it were exactly the same! When this apparent mistake was explained to me I asked how often the cost of medication exactly equals the cost of administering it and she said, "often." So the question is, which cost are they just pulling out of their butts? Do they look at the cost of the drug to determine how much it costs them to inject it, or do they look at the cost of injection and decide that happens to be the exact price of the drug?

while i cannot speak for the facility you are referring to, our facility has a set cost for injecting a drug, which varies by specific drug, and a cost for the drug itself. like any other commodity, the cost of drugs changes and our pharmacy price list reflects this. from what i have seen, the cost of the drug to the patient = hospital's cost * X. i am not exactly sure what X is, i'll have to pay more attention. as for the cost of injection being different, my take is that some drugs require more time/attention due to risk, risk being a major factor. thus, the riskier an injection is, the greater the injection cost.

[Bill Douglas]

I had exactly this with a dentist. THey kept asking for more and more payments. When I emailed and phoned asking what for they kept answering with a simplistic "there is a shortfall in payment". I asked for details of the work that, that I had to ask for about 6 times, then got details from the insurance company. They had been charging both parties almost randomly worked out charges with the dentist netting another 33% more than they should have. When I spoke to them about my findings they started doing "No speak English" (they were of Geek descent) on me. I presented my findings to the insurance company and changed dentists.

[Cajundaddy]

You have no idea how F'd up medical billing is and how many mistakes, omissions, admissions, and fraud take place. It is mind boggling.

One of my close friends is at the top of the food chain in medical billing and she made a really big error that cost her Co. major $$$$$$$$$$$. Not a fun day.

[Zeke]

Originally Posted by nynor

while i cannot speak for the facility you are referring to, our facility has a set cost for injecting a drug, which varies by specific drug, and a cost for the drug itself. like any other commodity, the cost of drugs changes and our pharmacy price list reflects this. from what i have seen, the cost of the drug to the patient = hospital's cost * X. i am not exactly sure what X is, i'll have to pay more attention. as for the cost of injection being different, my take is that some drugs require more time/attention due to risk, risk being a major factor. thus, the riskier an injection is, the greater the injection cost.

That's ridiculous.

[nynor]

Originally Posted by Zeke

That's ridiculous.

not really. its a LOT riskier to inject a chemotherapy drug than to give a low dose aspirin tablet or an injection of IV ibuprofen.

[Zeke]

Originally Posted by nynor

not really. its a LOT riskier to inject a chemotherapy drug than to give a low dose aspirin tablet or an injection of IV ibuprofen.

I see your point. I wasn't considering the complexities of chemo.

[nynor]

for the most part, administration cost of injections is within a few dollars, from what i have seen.

[Tobra]

The codes on the EOB should match the ones on your bill. It should indicate why a charge was disallowed. It may very well be that services that were covered last year are not now covered. I guarantee you that will be the case in 2014 and going forward.

One time, after the melanoma my wife had cut off her leg, that the dermatologist said was nothing, she went to an oncologist. They spent all of 5 minutes with her and sent her for a chest x ray. It was like an hour wait to get the x ray, so she split.

We got a bill for an extensive visit(hour of face to face time with the doctor), a chest x ray and the radiologist reading the chest x ray. I called them on it, and they said they billed for stuff when it was ordered, and bill for reading the films was linked to the order for the films to be done. They call it upcoding when you bill for a higher level of care than you provided. That, and billing for services that were never done is fraud.