4 Most Common Medical Billing Errors

Balance Billing

Your insurance company usually pays a claim as either "in-network" or "out-of-network," depending on whether or not the provider has a contract with your insurance company. If the provider is in the network, the insurance company pays a set amount that was agreed upon by the provider and the insurance company. The service provider agrees to write off the difference between the payment in the contract and the full amount billed for the service.

If the provider is not in the network, there is no agreement to cover the difference, so the patient will have to pay the difference. This is called "balance billing," and there are many ways for mistakes to happen with it.

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Since the in-network provider isn't writing off the difference, you'll be charged the higher amount. Many patients will pay this amount because the provider sent them a bill for it.

The insurance company pays the claim even though the provider is contracted and in the network.

A large group of in-network providers, like The Mayo Clinic, but one out-of-network provider in the group. If you happen to see that provider, your claim may be paid out-of-network, and your bill may not be adjusted as needed.

Overlapping Charges

Our country's current system for paying for health care is called "fee-for-service." This means that providers get paid for each service they give, and claims can have many codes that correspond to different procedures. Different ways are used to pay for different types of procedures, like hospital stays, well office visits, sick office visits, lab work, x-rays, and surgical procedures, to name a few. So, all bills should be looked at to make sure that the coded procedures were paid for correctly and that the bill from the provider is correct.

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Well visits and sick visits were both coded for the same day. Usually, 100% of the cost of a well-visit is covered, but the cost of a sick visit first goes toward your deductible. The difference can be talked about with the provider.

When more than one provider gives services on the same day, it's possible that the same procedures will be billed more than once. These bills should be checked to make sure the same service isn't paid to more than one provider. If that happens, the patient could get charged twice for the same service.

Time limits for filing

As part of a deal with insurance companies, claims must be made within a certain amount of time for them to be considered for payment. If the claim isn't sent in by the deadline, the service provider has to write off the whole charge.

WATCH FOR:

Bills from a service provider that say your insurance company denied the claim, which means you have to pay the full amount. The Explanation of Benefits (EOB) for that claim should be closely looked at to find out why the claim was denied. This will help figure out what the patient is responsible for.

Costs that aren't covered

A charge that is not covered by a patient's insurance is called a "non-covered charge." This is usually for a procedure that is cosmetic, not medically necessary, or considered experimental. All of these decisions can be appealed, but it may take a lot of knowledge about medicine and claims appeals.

The service provider has to tell you if a procedure might not be covered and should agree to help you with the appeals process if your claim is turned down.

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The provider doesn't tell the patient in full that a procedure is experimental or not covered. If that's the case, the bill that comes out of it can be negotiated or even taken care of for free.

Most medical billing mistakes are hard to figure out if you don't have a lot of experience in this area. Because mistakes happen often in all parts of medical billing, it's important to check for mistakes in all insurance claims and bills from providers. This review could lead to more money from your insurance company and less money from your doctors, so you can keep more of your money.

aJustSolutions is a Medical Billing Advocate that helps people audit, dispute, and negotiate their health care bills.

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