Do you check for Medical Billing Claim Errors?

People make mistakes, and that is a fact, so be prepared for medical billing claim errors to creep in too. It is second nature to check the slip at the grocery store and ensure that we were charged correctly and get the correct change. Through the years we have even begun to realize that banks often make mistakes and overcharge, so we check our bank statements with a fine-tooth comb every month, but what about medical bills? Do you check yours?

What may shock you to know is that according to the Medical Billing Advocates of America, the national association that checks medical bills for consumers, medical billing claim errors are made in approximately 80% of hospital bills. Although the statistics for bills from physicians’ offices are lower, they too often contain errors, so it is highly-recommended that you check every medical bill that you receive to ensure that you are not being overcharged or charged for a procedure or medication that you did not have.

Some of the medical billing claim errors are genuine mistakes, but do not think that the medical profession is above fraud, because according to a Washington, D.C.-based group of health insurers and state and federal law-enforcement officials, the National Health Care Anti-Fraud Association, around 3% of health-care spending, which amounts to a whopping $68 billion, is lost to fraud.

According to a recent survey done by the Employee Benefit Research Institute (EBRI), 60% of Americans with health insurance are paying more and more out-of-pocket medical expenses than before. This is impinging on their household expenses and making it difficult for them to afford some of the basic necessities of life.

Common Medical Billing Claim Errors

It very often happens that one wonders what happened that a simple surgery or medical process has suddenly evolved into a huge medical bill, but most of us also seem to think that the medical profession does not make mistakes. It is not easy to track what has happened or even to spot where the mistakes may be, but it is necessary that we do scrutinize our medical bills carefully.

Some of the most common medical billing claim errors that are made are:

  • Billing for cancelled tests or services
  • Bill amount totaling error
  • Billing for more operating-room time than was used
  • Duplicate orders for lab work, tests or procedures
  • No match between the ICD-9-CM code and CPT code
  • Procedure of the claim was not fully furnished by the other party
  • Place of service code is not mentioned
  • Physician’s ID not available
  • Service/treatment given in an invalid place of service or center
  • Service given was not a medical necessity
  • Type of service code not mentioned
  • Treatment/service provided was not validated
  • Wrong date of service given
  • Wrong rates were charged
  • Wrong patient identification number given
  • Wrong ICD-9-CM code with missing digits

If you suspect that medical billing claim errors have been made on your account, it is imperative that you attend to the problem immediately to avoid lengthy delays in payment.

Even though it is difficult to spot medical billing claim errors, there are certain things that one can do to ensure that what you are charged for is what you received. By keeping a strict record of everything and following certain guidelines you can ensure that when you or one of your family have a medical procedure done, you are not paying for anything that were not legitimately incurred.

Check Fees Beforehand

The best way to make provision for any procedure, test or lab work that needs to be done is to check what the costs are beforehand. Insurance companies have separate contracts with providers that determine how much they will pay that provider, so there is no blanket fee list that you can check to determine what the costs of a procedure will be.

When trying to determine what the costs of a medical procedure are likely to be there are certain steps that you will have to take:

  1. Phone the provider and ask what the costs will be and what Common Procedural Terminology (CPT) codes will be submitted to your insurer. These five-digit codes are used by health-care providers to bill for procedures and services, and are different to the codes used by hospitals. Hospitals use the Healthcare Common Procedural Coding System (HCPCS) system of coding, which consists of 5 digits that have certain letters added, for products, services and medical equipment.
  2. Call the toll-free number supplied by your plan and request an estimate of what your plan will cover for the procedure or service and how much of that you are personally responsible for. Many insurers pay their members rewards for discovering medical billing claim errors.
  3. If hospitalization is called for, contact the hospital or clinic and ascertain what the room-and-board fee will be, and what items are not covered by that fee. You can generally easily save on some of the things that may not be covered, such as tissues or gowns, by taking your own. Get your doctor to organize that you be allowed to bring your own prescription medication from home so that you will not have to pay inflated hospital prices.
  4. Confirm that everyone who is going to treat you participates in your insurance plan.

Keep a List of Treatments

Although it may sometimes be difficult, keeping a list of each treatment or procedure, as well as nay medication that you are given whilst in hospital, is a very good way of keeping track of what you should be charged for. If it is not possible for you to do it then a relative or friend can do it for you, as well as they can. Even if you do not manage to make a complete list of every single thing, a list of the most important items will be beneficial when checking your account for medical billing claim errors.

Review All Bills Immediately

The first statement you will likely get is a summary notice from Medicare or an explanation of benefits (EOB) from your insurance company, which will inform you of the total amount of all procedures, the amount which your plan covers, and the amount owed by you in co-payments and deductibles.

Compare all bills that you get from your physicians, checking the list of procedures performed, the medications charged for, and any other charges. If you have any queries phone the provider’s office directly, and request an itemized billing where certain charges such as lab tests are grouped together. This is important so that you can check that no medical billing claim errors have been made.

Hospital stays generally generate summary bills, which typically list most of the charges under very broad categories, such as surgical supplies, radiology or pharmacy. This can be confusing, and under the Patient’s Bill of Rights adopted by the American Hospital Association you are well within your rights to request a detailed account, which the hospital must provide free of charge.

If you are still having a problem understanding all the charges and feel that there may be medical billing claim errors, you can ask the medical-records department of the hospital to supply you with copies of your doctors’ orders and the nursing notes, which will include all medications and treatments and procedures you had. Ask for a copy of the UBO4 too; that is the detailed bill which is sent to the insurer by the hospital.

How to Handle Medical Billing Claim Errors

If you find medical billing claim errors it is important that you call your provider immediately and ask their billing department to correct the error. Keep a record of all the calls you make, including the name of the person to whom you spoke, as well as records of any other correspondence. These may prove to be very important in getting the problems resolved.

If you cannot get the problems resolved this way then it may be prudent to call your insurance company’s representative or fraud department to resolve the matter. If the matter is still not resolved then you can try communicating with your state consumer-protection agency or your state attorney general’s office.

If you do not manage to resolve your queries before payment is due, do not just ignore the bills. Even if you have a dispute and feel that there are medical billing claim errors, you should at least pay the portion of the bill that is not in dispute in order to keep your credit score from being affected. Many companies will report non-payment of accounts if they have not be paid within 60 days, so if the problem has not been resolved within that time it is a good idea to check your credit reports at and to write to the credit bureaus immediately if the disputed bills appear as unpaid on your report. Explain to the bureau that the account is in dispute because of medical billing claim errors, and ask them to review your complaint and to correct your report as soon as possible.