What are my options? Medical Bill/Insurance related

[Joker]

My son had a routine appointment last November and there were three separate EOBs. One was for vaccinations and it has been coded wrong twice. The first time the insurance company approved it with the wrong code and said we owe $500. They denied the resubmitted claim. The first time it was coded as pain management and the second as iron deficiency. The insurance company can see it was for vaccines but because of the code all they keep saying is they have to coordinate with the provider to get them to submit a correct claim. The provider's billing called me this morning to say they were done and I owe the money. Now, they're just saying over and over it isn't preventative.  

I feel like I'm losing my mind going round and round in circles and everyone is being an idiot. I have all the paperwork from dealing with this over the past six months including the itemized statement that clearly shows it was for two vaccines that are listed as covered by my insurance. Where can I go from here? 

Edited May 15, 2019 by Joker

[Jean in Newcastle]

You can start an appeal with the insurance company.  (The back of my EOBs tells how to do this for my insurance.  Your insurance must list it somewhere.)  And yes, normal vaccines are 100% covered by Obamacare and I don't believe that that part has been dismantled.

[TechWife]

Is this an outside billing company? If so, call the provider and talk to the office manager. Make her read the visit notes and see that the correct codes are sent to the billing company and that the billing company follows through and files a corrected claim.

It is the job of the physician to code the visits correctly (often with staff assistance). The billing company can only do what they are told to do.

Be prepared for the fact that the physician's notes may not accurately reflect what when on during the visit. It happens. Then you will need to work with the office to get the records corrected. If they won't correct them - then you have a right to add a letter to the medical record to state why you dispute the accuracy of the record. After that is added to the medical record, file an appeal with the insurance company and include the physician's note from the visit.

 

 

 

[Joker]

3 hours ago, TechWife said:

Is this an outside billing company? If so, call the provider and talk to the office manager. Make her read the visit notes and see that the correct codes are sent to the billing company and that the billing company follows through and files a corrected claim.

It is the job of the physician to code the visits correctly (often with staff assistance). The billing company can only do what they are told to do.

Be prepared for the fact that the physician's notes may not accurately reflect what when on during the visit. It happens. Then you will need to work with the office to get the records corrected. If they won't correct them - then you have a right to add a letter to the medical record to state why you dispute the accuracy of the record. After that is added to the medical record, file an appeal with the insurance company and include the physician's note from the visit.

 

 

 

This is a physician located within a hospital so the hospital billing department handles it. I have reached out to the doctor's office and they said they made sure the billing department understood they were routine vaccines. They billed the other two charges differently and this one they billed through the hospital side of things and then didn't code it right. It seems everyone admits to it being inaccurate but now the billing department is saying they aren't going to resubmit again to correct it. I did reach out to the Director of Operations at the hospital and she got right back with me that she is going to sit down with the head of billing to go over it and will get back with me by end of week, so I'm feeling better. 

At one point they told me that this was actually a hospital services facility fee. I know they can charge me for one but I would assume they just couldn't pick the most expensive bill and call that the fee. I would assume they would still need to code the vaccines correctly and then also bill for that fee. They haven't claimed that the last few times I've spoken with anyone, though.

I also contacted the insurance company again and asked about a formal appeal. So, now I have the paperwork for that if this isn't sorted out by next week. The insurance rep I spoke with today did seem a bit stunned that I was told they refused to submit again to get it correct. The fact they tried to resubmit once already with a new code shows they got it wrong the first time. 

Edited May 15, 2019 by Joker

[TechWife]

21 minutes ago, Joker said:

This is a physician located within a hospital so the hospital billing department handles it. I have reached out to the doctor's office and they said they made sure the billing department understood they were routine vaccines. They billed the other two charges differently and this one they billed through the hospital side of things and then didn't code it right. It seems everyone admits to it being inaccurate but now the billing department is saying they aren't going to resubmit again to correct it. I did reach out to the Director of Operations at the hospital and she got right back with me that she is going to sit down with the head of billing to go over it and will get back with me by end of week, so I'm feeling better. 

At one point they told me that this was actually a hospital services facility fee. I know they can charge me for one but I would assume they just couldn't pick the most expensive bill and call that the fee. I would assume they would still need to code the vaccines correctly and then also bill for that fee. They haven't claimed that the last few times I've spoken with anyone, though.

I also contacted the insurance company again and asked about a formal appeal. So, now I have the paperwork for that if this isn't sorted out by next week. The insurance rep I spoke with today did seem a bit stunned that I was told they refused to submit again to get it correct. The fact they tried to resubmit once already with a new code shows they got it wrong the first time. 

Good - the Operations Director should be able to straighten it out. It's absurd that the billing office just decided they were done with it when they are the ones that made the errors. That's a serious patient experience issue. If you don't get the results you need, I suggest that you contact the patient advocate/patient experience office of the hospital and file a written complaint. By law they are required to respond to those. The industry standard is within seven days, although that time frame isn't law. Since this is a hospital owned practice, this is an avenue available to you. Private practice patients don't have that avenue available from a legislative perspective.