Reviewing medical bills and insurance claims can help you spot costly errors

Although medical care is expensive, in some cases the amount of your bill may be higher than it should be due to billing errors. While errors can and do occur on any medical bill, they are more common and often more costly on bills for:

• Inpatient hospital care
• Complex medical procedures
• Specialist care
• Care delivered by providers who are outside your health insurance network

A survey published in JAMA Forum  found that 1 in 5 people received a medical bill that they felt was incorrect or that they could not afford to pay. More than a third of those people did not contact the provider’s billing office about the billing error, saying they did not think that disputing the bill would make a difference in what they were charged. But the survey also discovered that taking steps to address the error was worth the effort, resulting in the error being corrected 75% of the time.

What causes billing and insurance claim errors?

There are several reasons for the significant number errors that occur on medical bills each year. Complicated billing systems, for example, play a role. There are more than 155,000 ICD codes, the system that doctors, hospitals, and other healthcare providers use to classify diagnoses, symptoms, and procedures performed. With such a large number of codes, which are updated yearly, there’s a high potential for the use of incorrect codes on medical bills submitted to health insurers.

Other common errors include billing for a service twice, billing for a service you did not receive or one that was cancelled, and the provider failing to submit your claims to your insurer and billing you for the full amount of the bill rather than your coinsurance.

Your medical costs will also be higher if you receive care from a provider who is not in your insurance network. While you may choose an out-of-network provider in some situations like being diagnosed with a rare or complex condition, you may also unwittingly receive care from out-of-network providers. This is especially common when you receive hospital care. The hospital may be in-network, but the anesthesiologist or consulting specialist may not, for example.

Errors on insurance claims, for example incorrectly completed claim forms and lack of supporting documentation, can be another source of higher out-of-pocket costs.

What you can do to guard against the high cost of billing and insurance errors

• Get an itemized bill. The first step in reducing the cost of medical errors is spotting them before you pay the bill. Ask your providers for itemized bills so you can check them for accuracy. By some estimates, about 80% of medical bills contain errors that increase what you owe. Common errors include upcoding (using the billing code for a more expensive service), charges for cancelled or refused care, duplicate charges, and incorrect balance billing for covered, in-network care.
• Review every bill in detail. If you find a mistake, work with the provider to get it corrected. You may also have some protections under the No Suprises Act.
• Common billing and insurance errors to check for. When reviewing your bills and insurance explanations of benefits forms, look for incorrect personal information, such as a misspelling of your name or wrong middle initial, wrong address or Social Security number, or wrong insurance ID number. These mistakes can result in your insurance claim being denied for care that should have been covered. Look for separate charges for services that should have been billed under a single ICD code, for example billing separately for the incision and closure of the incision during a surgical procedure.
• Look for balance billing for in-network care. In-network providers agree to accept the insurance company’s reimbursement as payment in full after you’ve met any deductible and coinsurance. You are not responsible for paying the difference between what the provider charges and the amount the insurance company pays them.
• Get help from a billing advocate. For complicated or large bills or if you have a large number of bills because you’re living with a chronic condition or undergoing treatment over a long period of time for a condition like cancer, your PinnacleCare Health Advisor can connect you with our in-house billing advocates who can work to get the errors corrected on your behalf.

Our advocates helped one member who received an unexpected $3,000 bill because the hospital, which was in-network, failed to get one of its providers credentialed as a participating provider. For another member, our advocates worked with the member’s insurer to get full coverage for a $7,500 anesthesia bill for knee replacement surgery. The hospital and surgeon were in-network, but the member was not informed that the anesthesiologist was not.

PinnacleCare can help

Connect with the PinnacleCare team today to learn how we can support your complete health journey, including helping you manage your medical bills.

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PinnacleCare is a member of the Sun Life Financial Inc. (“Sun Life”) family of companies. PinnacleCare and its employees do not diagnose medical conditions, recommend treatment options or provide medical care, and any information or services provided should not be considered medical advice. Any medical decisions should be made only after consultation with and at the direction of your medical provider. Any person or entity who provides health care services following a referral or other service provided does so independently and not as an agent or representative of PinnacleCare.

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