How to avoid surprises and errors in medical bills!

Updated: Oct 13, 2018


Medical Billing secrets

Unpleasant surprises and errors in medical billing are common - how do you avoid them?


Health care network practices and medical billing errors leave many healthcare customers with a hefty bill, unexpected. To increase your awareness, we discuss a few examples and facts:


  • The Department of Financial Services in NY received a complaint from a consumer with preferred provider organization coverage who went to a participating radiology facility for her annual mammogram. The consumer verified ahead of time that the facility participated with her insurer. However, the consumer received a bill for $110 from a radiologist who read her mammogram. Even though the facility was linked with her insurer, the radiologist was not. The insurer allowed $58.64 (based on 150% of the Medicare fee schedule) for the radiologist, which was applied towards the consumer’s $500 deductible for out-of-network services. The consumer was responsible for paying the radiologist’s bill in full.

  • The same happened to a consumer whose child had open heart surgery at a participating hospital. The consumer was not told that a non-participating assistant surgeon would be used. The non-participating assistant surgeon’s bill was $6,400. The insurer paid $1,400, and the consumer was responsible for $5,000.

  • A consumer who had a brain hemorrhage and was transferred on an emergency basis from one in-network hospital to another in-network hospital that had the capabilities of performing neurosurgery. The neurosurgeon who treated the consumer was out-of-network and charged the consumer $40,091. The insurer covered the services as out-of-network and paid $8,386 according to its set fee schedule. The consumer was left with a balance-bill of nearly $32,000.

Now here are the facts that make such unpleasant medical surprises possible and a daily reality:

  • A recent study of health care networks for the three largest insurers in the lone star state, Texas, found something interesting: 20% of hospitals had no in-network emergency department physicians (for one such insurer, over 50% of the network hospitals had no in-network emergency department physicians).

  • In some critical situations in which the consumer is treated by a non-network provider, the insurance health plan may agree to compensate the provider at a certain level, but a provider can "balance-bill" the patient for any additional charges since there is no contractual commitment between health insurers and emergency non-network providers to accept the health plan’s payment as payment in full.

Here are some other medical billing errors to look out for:

  • Common mistakes made in medical billing include duplicate billing where both you and the insurance company gets billed for the same procedure.

  • Another common medical billing mistake is unbundling where the consumer is charged for each separate therapeutic process that should have ordinarily be billed together as one treatment.

  • Also look out for up-coding charges; a few unscrupulous doctors or hospitals use improper billing codes and charge customers for a more expensive service than what was actually done, like charging you for a minor surgery when you only went for a flu shot.

The consequences can be large and expensive for an unaware consumer, but don't fear - we at Explain.Care are developing a solution to help you carefully select the right health insurance plan and medical service provider, and to identify and resolve any medical billing errors! Sign up now on on the Explain.Care homepage to receive updates!


References :

Balance Billing: How Are States Protecting Consumers from Unexpected Charges?

Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much


 Copyright © 2018- 2019, Explain.Care, Inc. - All rights reserved.

Office: San Jose CA, 95124

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