Jim’s Take

I recently saw an item in a health-related publication I follow.  Parts of it were a surprise to me.  And from him I’ve learned a lesson that can help YOU, dear Reader

Dr. Bill Hennessey is the founder of Pratter, Inc.  They are a Pittsburgh area consultant that help health plans and employers and individuals make sure that they aren’t overcharged, shafted, or otherwise abused by health providers, particularly hospitals and other facilities.

At any rate, he wrote about denied charges, aka “surprise medical bills.”

These happen when your carrier decides for one reason or another to NOT COVER your procedure.  There are a number of reasons why they choose not to cover your claim:

  • It may be a “not covered” service under your plan – not everything is always covered
  • They may deem – in their self-aggrandized opinion – that it’s a “not necessary”
  • It may be “experimental”
  • You may need to submit more documentation to the carrier

Luckily, Dr. Hennessey gives a good outline of what to do when this horrifying situation arises.  Here is a summary of what he suggests.

Save and follow these suggestions.  Print them out to give your employees, or better yet, if you’re a BBI client, call us.  We’ll help.

Best Initial Strategy

Dr. Hennessey suggests that if you are going to have a procedure done that you avoid putting yourself in the position of ever having the claims denied, i.e. be proactive.

Best way to do that??  Insist on signing a paper document BEFORE the time of service that says, “I agree to pay only for medical care for which pricing is disclosed before the time of service.”

It’s probably not a bad idea to prepare that yourself.  Present it, refuse to have the service performed unless they agree and sign off on that piece of paper (either your prepared one or the provider’s version.

If they refuse to acknowledge your request, you probably ought not use that facility.  After all, you’re only asking them to acknowledge that you want to get what it is that you’re expected to pay for If they do provide such a document, initial and ask for a copy.

Keep it handy.

Preparing to Do Battle

If that doesn’t work out and you do get a bill, here’s what to do initially.

First, pay the provider or hospital NOTHING until you receive TWO things: 1) an itemized bill from the provider and 2) your carrier’s Explanation of Benefits (EOB).

The EOB will tell you why the carrier didn’t pay the bill.

The itemized bill will show every single procedure they performed.  Guess what?  They frequently bill for procedures that were never performed.  If that’s the case, REFUSE to pay for any service you didn’t receive.

Second, go back to the doctor/facility that ordered/performed the procedure or service that you did receive.  Talk to the billing department and ask them if they can resubmit the claim either using different diagnosis codes (called ICD-10) or billing codes (called CPT codes).

These are the codes that the insurance company’s computer looks at (you’re seldom denied as the result of a human being making a decision – this is all programmed into their “auto-adjudication software” which is the lazy and cheap way that they process claims.  There may be multiple codes that accurately define your condition or diagnosis (there are 68,000 diagnostic codes in use today!!)  It may be that the carrier will accept one code but not another.

Third, call the provider you used.  DON’T let them know that you have coverage or that your claim was denied.  Instead, ask what the cash price for your service is, and either tell them you don’t have health insurance or that you have a high deductible plan.  That price becomes your objective.  That’s how much you want to pay.

Fourth, call your carrier.  Pretend you are yet to get the service and ask them what you will have to pay if the procedure is covered and you haven’t yet met your deductible.  This will give you the price that the carrier has negotiated via its discount from list price.

What’s more, you shouldn’t ever pay more than this.  It’s the bottom line, worst-case scenario.  The “list price” is a price that is NEVER paid by anyone.  It’s a complete fantasy, despite the provider’s claims to the contrary.

Fighting the Good Fight – and Winning

Now you go into action … by sitting on your hands.  DO NOTHING.

If you can’t stand waiting, go ahead and call the billing department, but don’t let them abuse you.  Hang up if they leave you on hold too long.

Eventually – three to nine months after you’re first billed – you will get a call from the billing department.

When you talk to them don’t be nasty – that’s a losing battle.

  1. Start by immediately asking for the name, title, and direct dial phone number of the person who is calling. You want to establish that you’re a solid business person and don’t plan to be buffaloed.
  2. Explain that you aren’t in the business of writing blank checks and that you need an itemized bill that contains ALL billing codes. Absent that, you’re not paying.
  3. If the billing department people are confrontational or pushy and threaten to “take action” or “pursue you,” inform them that;
    1. They didn’t provide you with “known pricing” (assuming that you never got the first document we suggested you get) in advance of the performance of the service.
    2. That lack of knowledge is a violation of Section 2718 of the ACA (Affordable Care Act) on their part.
    3. They are therefore in violation of Federal Law, and
    4. You will report them to the Center for Medicare Services (CMS) for violating the law.
    5. Do it if you have to – you can create as much trouble for them as they can for you. Fight back.

For your own reference – and be prepared to email this to the billing department – here is the exact language of 42 USC 300gg-18 (e), according to some the most ignored part of the ACA:

(e) Standard hospital charges

Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1395ww (d)(4) of this title.

Good luck, and Carpe diem!!