THE BLOG

How Do I Spot Medical Billing Errors?

02/25/2015 10:21 am ET | Updated Apr 27, 2015
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This weekly Q&A addresses questions from real patients about health care costs. Have a question you'd like to see answered? Submit it to AskChristina@nerdwallet.com.

Question:

After my wife's recent hospital stay, we have a stack of bills. All of the providers were in our health insurance network, but because of our deductible, we owe a considerable amount (several thousand dollars). I've heard these bills frequently contain mistakes; how do I spot them to ensure we aren't paying more than we need to be?

Answer:

The complex world of medical billing is ripe for errors. As many as 250 people -- from the nurse to the medical coder -- could be involved in generating just one bill. With all of those hands touching the bill that will ultimately end up in your mailbox, it's no wonder some experts estimate as many as 80 percent contain mistakes.

Because these bills have a unique potential to send consumers like you into considerable debt, identifying those errors is crucial.

It isn't clear how many billing mistakes are caught and how many fly under the radar, with patients like your wife picking up the tab. Your motivation to spot these errors right away is commendable, so let's talk about how to go about it.

First off, medical bills are difficult to decipher. They are loaded with numerical codes, confusing abbreviations, charges and payments. So the primary step in identifying errors lies in understanding exactly what you're looking at and not being afraid to admit when something is confusing.

As you go through your bills, mark everything you have a question about, so that you're able to address these concerns with the billing department later.

Step 1: Request itemized copies of all bills.

When a medical provider sends you a bill, it's normally a summary. It will list amounts due under categories like "laboratory" or "miscellaneous," but without an itemized bill, you won't have any insight into what these charges are actually for.

An itemized medical bill will list specific medical codes, known as Current Procedural Terminology (CPT) codes for each charge. If you're lucky, they'll also provide insight into what the codes mean. If not, you can look up the codes on the website of the American Medical Association.

If the bill you receive isn't itemized, call the billing office right away and request one. Hospitals and doctors offices are required to provide them when requested, though few do so voluntarily.

Step 2: Verify dates of service, identifying information.

When you have your itemized bill, begin by checking the simple things. Ensure all of your contact information, date of birth and insurance information are correct. Also double-check your dates of service. These seemingly small mistakes are quite common, but they can affect your insurance coverage or how much of the bill counts toward your deductible.

Step 3: Compare your EOB to your bill.

For each bill, you should also receive an Explanation of Benefits (EOB) summary from your insurance provider. This will illustrate how much of each charge was covered by your insurer and how much is your responsibility. Again, check for the simplest mistakes first, comparing dates of service and identifying information. Then, compare the charges.

Step 4: Review all itemized charges.

Double check that your wife did, in fact, receive all of the medical services you're being charged for. Also, look for charges that show up more than once.

As you look at each entry on your bill, duplicate charges could stick out like a sore thumb. Remember, if your wife repeatedly received the same medication, it could appear as separate charges. But, if a service or one-time medication is charged multiple times, it's likely a mistake. Mark any questionable charges so you can easily find them later.

Step 5: Look for unbundling errors.

Unbundling errors are some of the most difficult mistakes to spot. Some procedures are bundled together because they are frequently performed together. A "room fee," for example, represents a bundle of goods and services. Charging you a room fee and charging you for the individual components that are included in that bundle would be an overcharge.

Spotting these can be hard, but if you see any items that shouldn't be charged separately -- like surgery and the incision -- flag them.

Step 6: Review charges for the operating room.

Because your wife had surgery, you will receive bills for both the operating room and the time under anesthesia. These could come separately, from the hospital and the anesthesiologist. Compare the charges to the amount of time your wife was actually in surgery. Because they are often billed in 15-minute increments, paying for an extra half hour could add a considerable amount to your total due.

Step 7: Check for "upcoding."

Upcoding involves billing someone for a more serious (and expensive) charge than warranted. For instance, if your wife entered the hospital through the emergency room, walking through the door but in pain, she shouldn't be charged the same as a patient who had to be wheeled in suffering from cardiac arrest.

Like unbundling, upcoding can be difficult to spot. If any charges are suspicious or simply seem far too high, mark them so you can ask about them later.

Step 8: Call the billing office.

In most cases, billing representatives are willing to answer your questions. So once you've reviewed the bills, flagging duplicates, possible bundling questions, or other errors, set aside some time to call.

Take your time with the call and don't be afraid to ask all of your questions. You and your wife are the customers here, and the medical providers are being paid for a service. You'll get the best results if you are cordial even when frustrated, but don't be afraid to ask the tough questions and get clarification when the answers aren't clear.

Once you settle on the correct amount due, know that medical providers are often willing to negotiate. Whether you want to discuss payment arrangements or ask for a lower balance altogether, these questions are not off-limits. Ultimately, they want you to pay and are often willing to work with you to make that happen.

Step 9: If needed, consider getting help from a medical bill advocate.

Medical billing advocates work for patients by helping spot bill errors and even negotiating lower balances with medical providers. This is a viable option if analyzing your wife's bills proves too challenging, or if the billing offices are being difficult.

While health insurance companies use software to identify medical billing errors, you don't have that luxury. Reviewing your medical bills will take some time and effort, but if the tedious process saves you some money, it will be well worth it.