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Demystifying Medical Bills - the Impossible?

Since we're still on the topic of pediatrician's, Rebecca's interested hearing if anyone has experienced billing woes:

I am in the midst of an conflict with my pediatrician's office regarding billing practices, and it has got me wondering how widespread the problem may be...so I wanted to inquire if other uMs might have had similar difficulties.

My family has an insurance policy through Regence BC/BS which includes 100% well baby coverage for 8 pediatricians visits in the first 24 months of life. The ped group that I had chosen has twice billed two visits in my daughters first 9 months of life with diagnosis codes, thereby resulting in only partial coverage by insurance and me getting a bill. What is so frustrating is that we visited our pediatricians under the impression that they were "well child" visits...we did not make the appointments with specific complaints. Upon researching the charges with my insurance company, I have been surprised to discover the diagnoses resulting in these charges...one of the two visits in our case was "functional disorder of the gastrointestinal system"...doctor speak for constipation. I had mentioned that my daughter was occasionally constipated at that visit, but it was simply mentioned in a conversation regarding the well being of my child.

I am a physician, and perhaps since I have just finished my training and have not yet practiced on my own, I am naive to billing practices. But this does not seem right. It seems to me a clear example of why health care costs are so high.... Anyone out there with similar problems? Thanks!


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We had problems in the beginning with our ped office & insurance, b/c the well-baby visits were being billed as adult vs. baby, so after the 2nd visit they were all billed full-charge (this was back in TN with diff insurance). We worked it out after many frustrating phone calls.

It definitely sounds like billing "error" (um, I'd say fraud). If you can't work this out quickly and easily, I'd start looking up effective ways to report your ped's office and switch peds immediately. I'd guess if they are unethical about billing that that spills into other types of care too. I wish I had more concrete info for you, sorry. Let us know what happens?

Ah the wonderful world of HIPAA X12 billing.
It is a known practice to try and upcharge the Payer for visits with a related "diagnosis" that has a higher negotiated fee. As a parent of a child or as a patient yourself, it is worth examining the diagnoses closely when you feel a charge has been passed on to you that is inappropriate.

Is it fraud? Its sort of like breaking the speed limit. Too many do it, and the penalty makes it worth the risk. Is it a result of our goofy hybrid health system? Absolutely. Is it widespread? Of course. Can you protect yourself? You can always examine your statements and invoices and insist on solutions and explanations when something looks off. But 95% of people don't look or read it, and so cost continue to be passed onto us through our employer, taxes, and co-pays.

When I gave birth to my son by c/s, our hospital bill was something like $26,000. Strike that. OUR bill was $10. The insurance company's bill was 26k. We looked at the itemized bill and saw they had billed for foodservice for both me and my son. Yeah, my breastfed newborn ate $3,000 in hospital cafeteria food. And he was billed for his own room, too, even though I never let him out of my arms for a second. I could go on and on. It was insane. When we asked about these things, the hospital said, "Why does it matter to you? Your insurance pays for it." No kidding.

Yes, in our case "failure to thrive" was the fancy wording for a weight check that we went in for several weeks ago. Luckily, our insurance is incredible, but had I needed to come up with the cash you can be sure I would have been on the phone with a fight on my hands. I could take him to the grocery store and do a better job in the produce aisle than the nurses do in the doctor's office of weighing these guys!

When I had BC/BS insurance, we were overwhelmed with trying to figure out what were out-of-pocket expenses. That was our primary insurance for about 8 years. I thought my experience was standard practice. Then, when we switched to Kaiser and the hospital bill was $100 for the birth of my second son. I never thought I'd say this. Even though we have several health plans to choose from, I'd opt for Kaiser in a heart beat. I have not had to deal with the burdensome paperwork that seems to be the BC/BS way of doing business.

Trying to decipher PPO plan medical bills can be a real nightmare, even for people like me who have worked in the health care industry for 15 years.

I've not seen a plan design like that before. In my work experience, "well care" usually meant the routine scheduled visits that babies have, like after birth, 3 month, 6 month, 9 month, 1-year, 18 month, etc. Anything that fell out of this category was usually paid under a different benefit category for physician visits.

If you feel that there is an issue with the bill, I would definitely question it with the ped group and your health care plan.

If your pediatrician and/or BCBS are not readily willing to correct the problem for you, consider the state's consumer protection resources as well. For general consumer protection info, see http://www.doj.state.or.us/FinFraud/welcome3.htm. For specific, insurance-related consumer protection info (if BCBS is clearly part of the problem), see http://www.cbs.state.or.us/external/ins/docs/consumer/tomake.htm.

Billing codes and diagnosis codes are two different things. If your child has constipation, then it's appropriate to enter the diagnosis code. The problem is not in making the diagnosis, but in the billing. In this case, it sounds like two billing codes were entered, one for the routine well-child visit and another code for the other problem (essentially billing for both the well-visit and for another office visit for the additional problem). This is not fraud IF there is a problem that is not usually a routine well-visit topic, AND if that problem required additional history and physical, or additional time/counseling, beyond what is typically done for a well-child visit (for example, a routine well-visit plus 15 minutes managing diabetes). Doesn't sound like this was the case for your visits, so I would talk with your pediatrician's billing person.

Accurate billing is actually not that easy, so I wouldn't jump too quickly to accuse someone of fraud.

Oh, I hate this stuff! I just had a $100 piece of wax removed from own ear. That's right - for a plastic syringe full of warm water, a dishtowel (it really was a dishtowel!), and a plastic cup. Oh, and I guess the two minutes it took for the nurse to wash it out of my ear canal. My insurance called it a "surgical procedure." Sigh.

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