What to do about a medical overbilling?

Factual Questions
1

A few weeks ago, my wife makes an appointment for a pap smear as part of her updating birth control pills.

After the appointment she gets the statement from the insurance company, which says she ows $200 and that they won’t cover the appointment. She calls the insurance company and is told that the clinic coded the appointment as a physical, and that for someone in her age group, a physical is covered only once each three years. A pap smear would have been covered. My wife didn’t realize at the time she was getting a physical – she didn’t realize that if the physician’s assistant picked up her stethoscope it becomes a physical.

She next calls the billing department of the clinic, and she’s told that due to medicare regulations [she is not eligible for medicare in any way, and we have private insurance] the appointment cannot be recoded. The person at the clinic was kinda bitchy about it, also. Strike two.

She writes a letter to the business manager of the clinic saying essentially, “I wanted a pap smear, but I got a physical without being consulted about it. Unless you can help resolve this situation, I’ll have to ask the doctor every time he picks up a tongue depressor what he is doing and how it will be coded, then cross-reference my insurance manual. Of course this is unacceptable and I would prefer to find another clinic.”

She gets a call from her physician’s assistant (who did the exam) who chides her about how the clinic can not keep track of all the plans and what will be covered and what won’t. (True and not true, my wife’s coworkers say that their doctors will warn them about extra costs of additional procedures and the effects they may have within their plans.) When asked about the un-asked-for physical, the PA says she doesn’t update prescriptions without a physical. Without telling the patient, apparently.

That was strike three. We’ve exhaused what seemed like the normal and reasonable means of addressing this. We just received a note from the clinic asking for the $200 immediately.

My wife was thouroughly unimpressed with the level of customer service and won’t be going back (she might have even been satisfied with a half-assed “I’m sorry, we can’t change anything now, but we’ll be more attentive in the future,”). Is there any other avenue for recourse? Or is this standard operating procedure for clinics (not according to my wife’s informal survey) and we should forget about it and pay up?

2

For what it’s worth, I work in the medical billing office of a radiology clinic. Here goes:

Billing is generally done by means of a procedure code (CPT) and a diagnosis code (ICD). Evidently what happened in your wife’s case is that her procedure was coded correctly, but the reason for the visit (the ICD diagnosis code) was done incorrectly. Here are some possibilities. It may have been coded V70.0 instead of V72.3. (The bill probably has a diagnosis code such as this written on it.)

Medicare does not exactly regulate these codes as such. However, they are a very powerful organization and many offices depend on getting their bills paid by the big M, and as such those clinics tacitly code all procedures to any insurance company in the same manner that Medicare wishes to see them—and Medicare doesn’t like most of the V-codes. The clinic probably coded her visit automatically according to the Medicare protocol. (I can clearly imagine why Medicare does not believe a female pelvic exam is a valid procedure code for 95% of their elderly policyholders.)

I am no claim adjuster, but I am told that insurance companies sometimes rely on computers to tell them which claims are okay to pay: for any given procedure there are acceptable diagnosis codes for which they shall pay and all others get denied. Insurance companies often ask us to retroactively fudge a code so they can pay a claim. This can sometimes constitute fraud on our part so we decline to change coding when our code is clearly supported by the report of the exam that was done. We won’t, for example, change a bilateral mammogram to a routine screening mammogram simply on the basis of “well, you didn’t find anything, so just call it a screening.” However, mistakes do hapen. :slight_smile:

Sadly, I have to say that I agree with the clinic’s position that it is increasingly difficult for any doctor’s office to both accept any insurance coverage and be aware of how the various coverage plans will affect patient treatment. There are hundreds, if not thousands of medical insurance plans under slightly different umbrella companies, different plans, changing contract statuses, different processing centers, co-pays, rates of reimbursement, percent of allowables, monthly or yearly deductibles, etc., and to my knowledge, there is no central database where one can investigate the varied clauses of everyone’s coverage plans. Since the insurance company writes the check, I always advise patients to get that answer straight from the horse’s mouth.

Okay, so you want options. I can think of two, maybe three.

One, get your insurance company to write a letter to you asking for this change in coding. Their letter should say “we will pay for this procedure if the code is suitably revised.” It’s possible that the clinic will spring for the coding change if they have proof that the insurance company will cough up the dough. Alternately, get the insurance company to call the clinic and have them ask for the coding change directly.

Two, see if your wife had a referral for her pap: that is, a written order by the staff asking for a particular kind of exam. If you can demonstrate that the exam performed was not the same one ordered, you might have something to go on.

Three, you can try to contact the office of the insurance commissioner for your particular location. I know the state of Washington has one; you may have one or its equivalent in your jurisdiction. This office may help you become aware of whatever recourses are available to you, and/or lean on the insurance company to make them help you out.

In the meantime, see if the clinic will accept partial payments while you work out the issue with the insurance company. Good luck. I hope it works!

3

Feh. They’re committing fraud. She went in for a Pap smear, and they’re trying to get more money for it. Big, big mistake, writing that letter. When someone is charging you for a service that was not provided, never ever ever say that the service WAS provided. There was no physical exam, or your wife would have noticed.

At this point, you have little recourse. The insurance company isn’t going to bat for you (Why should they? It will cost them money), the Insurance Department has no authority over the clinic, and that letter pretty much kills any leverage you had. The only leverage you have left is not to pay the bill. That would probably do bad things to your credit rating, get you hassled by a collection agency, and other consequences that haven’t occurred to me yet.

It’s barely possible, though, that you can try a bluff: "I’m not paying this bill. I did not schedule a physical exam, I did not want a physical exam, I did not receive a physical exam, and if you don’t recode this to a Pap smear, you’re not getting jack. You’re committing fraud, and I’ll file charges with the District Attorney if I have to. And don’t hand me any B.S. about Medicare, because I’m not on Medicare – this is between you, me, and the insurance company.

4

The insurance policy is probably being handled by an agent. Either you going through an agent, or your employer. If that’s the case, bring them in on this.

I had a double billing a doctor’s office sent me to collections for. They absolutely wouldn’t correct it. They HUNG UP ON ME when I called about it. The insurance company told me it was my problem, though I’m in a PPO and part of their regs say that the doctors have to comply with their billing. I finally contacted the insurance agent for my company and told him to fix it.

If the clinic belongs to a PPO for your insurance, they are required to follow the rules the insurance company has put down. Your wife’s clinic didn’t. Try to use that as leverage.

Good luck.

5

I’d have to check the wording of the letter to see if she admitted that she did receive one. It said essentially that she didn’t ask for one and didn’t realize that she was getting one, and that the bill was the first clue. I don’t remember if it goes on to say that she now thinks she got one.

But why does it matter? If I order a bike pump from a bicycle catalog and a bicycle shows up on the front step and on the bill, I wouldn’t hesitate to say that a bike showed up instead of a bike pump. What’s the difference?

6

Yeah, Nametag, something is hinky about the whole thing. Exactly who is trying to commit fraud here is, to my mind, still unclear. Either the clinic performed a Pap smear and coded it as a routine physical exam, or the clinic performed a physical exam and the insurance company wants it reclassified as a Pap smear. The OP’s wife only has her own personal knowledge of what was done in the exam room on which to base any suppositions…not that I’m suggesting a woman could have a Pap smear done and not know it! It’s what else was done in that exam room that counts.

That’s why I suggested she work it from both ends, looking for a paper trail.

Under HIPAA laws, she has the right to inspect and copy her medical records (sometimes for a small fee, depending on the clinic), and there must be some kind of dictated exam report or notation indicating the date, time, and type of exam done. That’d be a great place to start. If the report shows the exam was a Pap smear, this may be enough proof for the insurance company to pay the claim.

She might also try to ask about printed clinic guidelines which require a new exam every time a prescription is renewed. I find that suspicious and highly unusual—scrips of all kinds probably must get renewed all the time. Mine generally last a month or less (not birth control, though: I’m a man). I don’t get twelve physicals a year! Few people do, I suspect. Perhaps she can locate the part of the clinic guidelines and find out exactly what exam is required upon renewal of birth control. It may say that the patient must have one physical exam within the last, oh, twelve months, in which case, she’s out of luck.

7

ok guys= I work in an OB GYN office doing coding and billing and I get this sort of thing from pts all the time. There is no code for just a pap smear- pts either come in for an annual gyn visit or they come in for a problem. The dx code used for an annual exam is V72.3, and the code is for a pelvic exam, a breast exam AND a pap smear. Our docs dont have pts come in , hop up on the table, stick in a swab, and say goodbye. Its an exam. Pts come in for a yearly ck to renew pills, they get a bp ck, weight, height, breast exam, pelvic exam,and pap. The only time our pts come in for just a pap and nothing else, is because they have had a complete exam in the past year, and the pap came back as abnormal. Of course, YMMV. I have pts ALWAYS asking me to change codes so insurance will pay, and this is insurance fraud as well, especially when it’s noted in the chart that the pt had a pelvic and breast exam along with the pap. And believe me , when we change codes , the insurance companies ALWAYS request the medical records to make sure the codes match the doctor’s notes.
On the other hand , we ask the patient no less than three times what exaclty they are in the office to have done, we have them sign a form to that effect, and they also get a notice stating many insurtances do not cover routine pap smears and exams. I have been successful many times appealing claims insurances when pts are told the policy covers a pap but not the exam. Since they go hand in hand, I send a letter, the doctor’s notes and a copy of the pt’s pap smear (with the pts written permission of course) to the appeals dept of the insurance and always end
up getting paid.