Medical Billing Offices:Swimming with Sharks

I would like start by stating, that I understand medical billing offices have a job to do.  What I am writing about is how the billing offices go about the business of recouping their money since the economic downturn.  With insurance raising premiums and the least expensive policies having higher deductibles and larger coinsurance, patients are being asked to pay more out of pocket.  Some inexpensive tiered  policies require only using local facilities and doctors, and if a specialty center is needed, the patient is responsible for anywhere from 50-80%.

If there is any insurance reimbursement denial, common practice is to charge the patient at the full billing price.  It is now designated as private pay and allows the rate to be doubled or tripled the insurance negotiated charge.  Once the determination is made that insurance will not pay for whatever reason, the patient is now at the mercy of the newly crafted policies enforced by the billing administrators.

What has come as a surprise to me, is how involved medical practitioners have been in determining the new policies.  I have sat in offices with patients and they have asked the doctor how much something may cost.  The common response is, “Oh I don’t know that, ask at the front desk”.  I stopped giving medical professionals a pass on this information for two reasons.

First, medical professionals have a responsibility to know how much their care costs and what the impact on a patient may be. Why wouldn’t you want to know how much your service, or a lab or a diagnostic test costs?

Second, Physician organizations often are the ones who set cost and policy.  Many know the cost,  insurance status and potential out of pocket responsibility.  I once had a client who’s mother had passed away from a rare cancer.  She kept getting bills from the oncologist.  I helped her apply for financial aide.  It got turned down which surprised me so I called my billing office contact.  In a hushed voice she told me it was the physician who approved any financial aid and that this particular oncologist always said no.  I told my client, who couldn’t understand why this doctor was causing such stress after the death of her mother.

In days gone by, calling a medical billing office for me as an advocate was a pleasant experience.  I could negotiate bill reduction, set up reasonable payment plans and organize financial assistance.  I could develop relationships with the business manager or supervisor and would sometimes discuss topics beyond the clients bills.  Those conversations are now few and far between.

One of my greatest shocks was being told by a small corporate owned hospital that even with a HIPAA release, they would not speak with me.  I was quite surprised.  I had to speak to the supervisor who was unwilling to bend for about fifteen minutes.  The reason I was being given was that they only spoke with the patient or the person who would pay the bill.  I ended up contacting the CFO of the hospital system  and worked out a deal.  I did get it done but why the hassle?

Here are some of the other changes I have run across.

It used to be possible to get a substantial reduction in the bill if paid in full with 10-15 days.  Now, out of the gate, the offer is 10-20%  These are usually bills that insurance wouldn’t pay so they are at the highest possible rate.  I have to present an offer from the start to get anywhere.

There are no more extended payment plans.  Everyone wants their money in six months.  It is rare that it can be extended to a year.  That may be acceptable to someone who’s bill is only $200 or less but if someone has a bill in thousands, it isn’t feasible.  One client told me, the monthly amount being requested was higher than the mortgage.

There is a rush to send bills to collections. Three months and you are out, even if you have been talking to the office.  It can take three months just to go through the appeals process.  I realize that businesses need the money for expenses but if a bill is in error or the insurance will eventually pay, then don’t send the bill to collections.

It is more difficult to get financial aid.  The criteria has become stricter and without mercy.  I had a billing office in Wyoming tell me that because my client had money in a retirement fund (a small amount), they said she could cash in the fund and pay them.  This was a hospital in a rural area of Wyoming and most people owed some money to the hospital.  They didn’t want to reduce the amount to insurance level nor allow long term payments.  It was a long process.

When these changes started to occur, I thought I had lost my touch.  I felt like the rug had been pulled out from under me.  I started asking colleagues and they all said the same thing.  The playing field rules had changed and no notification was given.  I had to shift my thinking and approach.

There are more mistakes on bills and insurance explanation of benefits.  Coding has become so complicated that many mistakes are made.  The problem is, unless you understand coding, it isn’t something you can readily identify.  Sometimes changing a code will get the insurance to reimburse.  I recommend to always get an itemized copy of the bill with the codes.  Codes are frequently incorrect.

Here are some tips to getting through the billing office maze.

1.Make sure the itemized bill matches the service provided.  Question the cost.  Billing offices are frequently wrong.

2. Talk to a supervisor.  Front line customer service people have no power to negotiate.  Essentially, they read from script.  Go as high up as necessary on the administrative chain necessary to get what you need.

3. If there is a problem with the insurance and the facility, as for a conference call with both.  If you can get the two to talk, problems can get resolved.

4. If you have a private pay bill, know how much you can afford before you begin to talk payment.  Remember, the facility is getting probably anywhere from double to triple what the insurance would reimburse.

5. Every call made, write down the date, time, name of the person spoken with and the essence of the conversation.  When possible record your conversation.

It is not easy working with billing offices.  I recommend deep breathes,  don’t loose your temper and know you are in for the long haul.  It is possible to get what works for you.