Errors in Medical Claims Processing Cost Health Care System Billions Each Year

Here’s a health insurance headache most readers can relate to: My son took a bad fall in an indoor soccer game this winter and fractured his wrist and pinkie toe. He was diagnosed and treated in a specialized emergency room at an orthopedic hospital that accepted our health insurance; in total we were there a very reasonable two hours and my son left sporting a wrist cast, sling and a surgical shoe. Before leaving I stopped by the reception desk to find out about co-payments and other charges we might have incurred: “Don’t worry,” the billing clerk told me, “we will submit all the charges to your insurance.”

The wrist healed quickly, the surgical shoe was abandoned after two days and my son eagerly went back to bouncing off the gym walls. Then the bill from the emergency room came. Among the assorted charges not covered by our insurance was $218 for a “short leg splint calf to foot.” As I mentioned, we left with a “shoe” that consisted of an inflexible sole held in place by Velcro straps—definitely not a “short leg splint.” As my family’s de facto health advocate who has spent countless hours battling overcharges, coverage denials and outright billing errors, I assumed a phone call to the billing service would clear this up. Well, five months and two subsequent statements later, I’ve just received “final notice” that if I don’t pay the splint charge it will be sent to a collection agency.

Undoubtedly there are few among us who haven't encountered similar insurance hassles; substitute blood test, MRI, anesthesia, out-of-network provider, brand-name drug or any number of medical devices or interventions for “short leg splint” and this becomes a universal tale. For cancer patients and those undergoing surgery and hospitalization these disputed charges become a more serious problem, adding up to tens of thousands of dollars in potential debt.

As has been the case with most of the coverage denials I’ve dealt with over the years, this current billing headache will likely be caused by a coding error that originated either at the provider or as my claim worked its way through the inner workings of our insurer. When doctors or hospitals bill insurers for their services, they must assign a code for each and every procedure, device, medication and test administered. Insurers process these codes with an eye trained on ferreting out discrepancies and (so it often seems) finding reasons to deny coverage or delay payment.

According to the American Medical Association (AMA), this process is far from efficient and quite error-prone. The doctor’s group released its annual National Health Insurer Report Card this week and found that 19.3%—almost one in five—of medical claims processed by the nation’s largest commercial health insurers is inaccurate. The report card found a 2% rise in claims processing errors over last year’s findings, which added “an estimated $1.5 billion in unnecessary administrative costs to the health system,” according to the AMA. The doctors' group estimates that if all health insurers were able to eliminate all claim payment errors, the health care system would save $17 billion a year.

Where would these savings take place? The AMA calculates that doctors’ offices spend an average of 20-plus hours each week dealing with what are called “claim edits.” In health insurance parlance these “edits” are basically discrepancies that arise between charges submitted by a provider and an insurer’s catalogue of covered services and interventions. When a claim receives an edit, it is kicked back to the provider (and usually the plan’s beneficiary) with a “reason code” for why the claim was rejected. Most often this occurs when a subscriber is deemed ineligible for coverage, or the medical coding doesn’t jive with a particular procedure, or if the charge submitted is not compatible with a negotiated rate, or the patient needed to have precertification, i.e approval from his insurer before he had an MRI or surgery…and so on and so on.

This is complicated enough. But it turns out that in the world of commercial insurance, there is no standardized “claim edit library,” so providers have to submit different claims information and respond to different error codes for each of the insurers they deal with.

Just writing this is making my head spin.

Some commercial insurers are doing a better job than others: “UnitedHealthcare came out on top of seven leading commercial health insurers with an accuracy rating of 90.23 percent,” according to the AMA. “Anthem Blue Cross Blue Shield had scored the worst of those measured with an accuracy rating of 61.05 percent.”

The most surprising finding from the AMA report card? It turns out that despite all the groaning about how the government operates an overly-generous and inefficient program, Medicare has the lowest claims error rate of all the insurers scored with an average accuracy rate of over 96 percent. As Ezra Klein noted on his Washington Post blog, this isn’t because Medicare indiscriminately covers every charge, fraudulent or not; “[Medicare] has moved aggressively to adopt electronic money transfers, while major insurers like Cigna and Humana are still sending checks. And it rejects more claims than Cigna, Aetna, or really anyone but Anthem. In other words, reality defies the stereotypes.”

The takeaway message from this year’s insurer report card is that the current medical claims processing strategy is still too labor-intensive, error-prone and far too fragmented. Practitioners and insurance companies must continue to adopt high-quality electronic billing and payment systems that can cut down on processing errors and remove the hassle of having to deal with both paper checks and electronic payments. The other key recommendation is that insurers adopt a standardized coding system for claims—similar perhaps to the one adopted several years ago by Medicare. The fact that a single provider could be dealing with hundreds, if not thousands, of sets of benefits for their patients is ludicrous. As Uwe Reinhardt, economics professor at Princeton and trustee of 900-bed Duke University Health System once told the Senate Finance Committee: "We have 900 billing clerks at Duke. I'm not sure we have a nurse per bed, but we have a billing clerk per bed. It's obscene."

The AMA’s report card highlights the administrative costs associated with inaccurate claims processing and focuses on the toll this takes on providers. But it generally ignores the fact that consumers are ultimately the ones left holding the bill for claims errors. If an insurer kicks back a charge and refuses payment to a provider, the responsibility shifts to us.

A report released in March from the Government Accountability Office (GAO) indicated that insurers denied coverage more frequently because of billing errors—such as duplicate claims or missing information—and for eligibility issues, (services were provided before coverage was initiated or without pre-certification) than because they deemed care medically inappropriate. 

The GAO report also found that when coverage denials were appealed, they were frequently reversed in the consumer's favor. For example, data from four of the six states that participated in the  agency’s study found that some 40-60% of consumer-initiated appeals resulted in the insurer reversing its original coverage denial.

In a recent article extolling the benefits of appealing an insurer’s denial, Kaiser Health News’ Michelle Andrews writes, “Claim denial rates vary significantly by insurer, according to the GAO report. In California, for example, the denial rate for six managed care insurers ranged from 6 percent to 40 percent in 2009. Whether you're insured by a plan that kicks out many claims or only a few, it may pay to appeal.” She adds, “…the odds are about 50/50 that if you appeal an insurer's decision, you'll win.”

Under the Patient Protection and Affordable Care Act, all patients will have to be notified that if a claim is denied, they have the right to an internal review by the insurer and also with an independent review board. More importantly, the health law provides $30 million for state-based consumer assistance programs that are supposed to help consumers fight denials and erroneous charges.

The Center for Medicare and Medicaid Services estimated that in 2009 private health insurers spent $471 per enrollee on administrative costs. This is a decline from a high of $507 in 2007, and will likely drop further as new provisions in the health reform law require companies to spend a larger percentage of premiums on patient care or face penalties. Achieving further cuts in the administrative costs of health care will require that insurers streamline their claims processing and convert to a more universal coding system. Only then will these savings move downstream to providers and, ultimately consumers.

In the meantime, I would hate to think that these “errors,” delays in payment and reflexive claim denials are really just ploys to increase insurer profits. So for now, I like millions of other annoyed Americans, will continue to test my endurance and keep following up on suspect medical charges and care denials. Now, when can I set aside an hour to wrangle with that collection agency?

30 thoughts on “Errors in Medical Claims Processing Cost Health Care System Billions Each Year

  1. “Just writing this is making my head spin.”
    Naomi-Likewise reading it.
    The systems are just too big and much too complex
    I don’t have any immediate answers
    Dr. Rick Lippin
    Southampton,Pa

  2. While having my varicose veins treated, I chatted with my doctor about health insurance. He said he was against the Affordable Care Act, but as we talked he admitted that dealing with Medicare was so much easier than working with insurance companies. He said that, while Medicare pays less, at least they pay quickly. Insurance companies, on the other hand, ask for more information, reject claims, and generally seem to find ways to delay payments.
    Has anyone calculated the added cost to health care from doctors having more support staff than nurses in their office? The private insurance system we have is so inefficient and wasteful – and this does not include profits.

  3. Sheesh!
    In a day of universal bar codes and scanners there is no reason to manually code any equipment or disposable supplies. A portable scanner could have tracked that splint as easily as a can of tuna, ordered a replacement for inventory purposes and noted the account to which it was billed. What am I missing?

  4. Medicare has well-established rules based on code combinations that appear on the claim. They will automatically reject or deny what is inappropriate based on these rules. SpeedECoder is software that contains all these rules at http://www.speedecoder.com.They include CCI bundling rules and LCD medical necessity rules. I don’t know why so many other payers do not do it like Medicare!

  5. Naomi-
    You are being too generous in calling this a billing error – it was likely intentional overbilling. In my personal experience, most medical bills are padded – a 5-minute visit billed as a 45-minute visit, a cursory ER examination billed as a level 4, a simple neeedle aspiration billed as incision or drainage, excision of a 3 mm lesion billed as excision of a 20 mm lesion. All of these bills passed insurance company screening, These were not clerical errors – They were adjusted by the treating physicians only when I told them that I was a physician who directly witnessed the procedure and would file a complaint to the state medical board about fraudulent billing.

  6. On October 1, 2013, ICD-10 is scheduled to go live replacing the ICD-9 coding system used by hospitals. This will take us from some 14,000 codes currently to 69,000. While academics are excited about the prospect of increased granularity to more thoroughly understand what’s going on in our healthcare system, we should get even more potential for both insurer claim edits and provider upcoding. In the meantime, both providers and insurers will have to spend tens of millions of dollars to reprogram their computers to get ready for the changeover.

  7. I’m with Marc on this.
    I’m dealing with a similar issue right now. A PA who saw me in the ER Fast track is trying to bill me for a pulse reading he did not do when I was seen for a back injury related to my part time hospice job.
    Complicating this is the fact I shouldn’t be getting billed at all: it’s a Workman’s Compensation claim, and they were told this when I registered and given all the relevant information.

  8. ‘Short leg splint’? New to me too even though I once worked in an orthopedic ward. But having our own lingo is one of the ways we doctors control the closed shop called Healthcare. However there is another important use of neologisms, acronyms and Latin & Greek phraseology in medicine. That as some of the commentators here have noticed is in the Art of Billing. Needless to say the publication of the ICD-10 will be helpful at least to doctors in this regard. Nevertheless the publication of that scholarly text will be topped in that very year by the publication of an even more useless (but VERY helpful to psychiatrists claiming money from insurance companies)text called the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) ‘Short leg splint?’ Wait till you read about the diagnosis of “Sexual Disorder Not Otherwise Specified” and “Oppositional Defiant Disorder” I wouldn’t be surprised if the American Psychiatric Association thinks that I suffer from the latter!

  9. I had a similar experience. My son broke his foot and the ER put him in a cast up to his upper thigh. When I got him to our family orthopedist, he took the cast off and said NO cast was necessary, just that my son should stay off the foot and wrap it if it made it more comfortable. Besides insurance paying for unnecessary expense, it put my son through a lot of unnecessary discomfort. It’s hard to argue in the ER at 3am, however…

  10. “The private insurance system we have is so inefficient and wasteful – and this does not include profits.”
    Denise the $700 per enrollee per year that Medicare loses to Fraud is higher then the total administratibve cost of private insurance including all their profit.

  11. Nate Ogden –
    Unfortunately, the rate of fraud in private insurance is largely unknown because, unlike Medicare and Medicaid which are mandated to investigate and pursue and publicize fraud, private insurers largely ignore fraud as an issue, since the cost of pursuing it is higher than the cost of accepting it.
    One of the few studies ever done on private insurance fraud, an investigation by newspapers in New Jersey, showed a higher rate of fraud in private insurance than in Medicare.
    The main form of waste in private insurance, however, is not fraud, money paid for profits, for advertising and underwriting, for sales, or for large salaries to top employees, but the money lost to the inability of private insurance to deal effectively with negotiations with providers. That is why, except for the brief period in the 90′s when private insurance made a concerted effort to control costs, private insurance consistently shows greater inflation and increased costs than Medicare year after year. This year, the growth of cost for private insurance was almost twice that of Medicare.
    Private insurers are by no means eager to continue paying this differential, but because of the power of providers in many areas of the country they are largely powerless to stop it. Medicare, on the other hand, can and does control costs and eliminate payment for many — but by no means all — wasteful procedures and tests. If the ACA is allowed to take effect, Medicare will be even more effective at that. Hopefully, private insurers will be able to hitch a ride on Medicare at that point — as they often do now — and reduce payments as well. The insurance exchanges, if allowed to take effect, will also give private insurers the chance to show customers exactly what they are paying for the costs exacted by powerful provider groups and make the choice of whether they want that cost or prefer to buy insurance that may give them fewer choices of providers but will cost much less.

  12. “unlike Medicare and Medicaid which are mandated to investigate and pursue and publicize fraud, private insurers largely ignore fraud as an issue,”
    Pat every client I have disagrees with you. If my plans had fraud even 1/10th of what Medicare does I would be fired and taken to court to reimburse the plan. In fact I would probably end up going to jail under ERISA for breaching my fiduciary duty. Not sure what you based this comment on but it is far from the truth.
    “That is why, except for the brief period in the 90′s when private insurance made a concerted effort to control costs, private insurance consistently shows greater inflation and increased costs than Medicare year after year.”
    Is that why Pat? It has nothing to do with Private Insurance benefits getting richer while Medicare pretty much hasn’t changed since 1965? In the 1960s 50% of an individual’s healthcare expenses were paid out of pocket, now that is down to 13%. Correct me if I am wrong but if that 37% of expenditures shifted from individual to private insurance wouldn’t their cost increase more than those covered by Medicare who have not seen any shift in benefits?
    “This year, the growth of cost for private insurance was almost twice that of Medicare.”
    Hum, this year…..wonder what might have happened this year that would have caused that….oh wait didn’t the government just pass a huge bill that requires private insurance to cover all sorts of things at 100%, do away with annual and lifetime limits, cover sick Medicaid kids till age 26 and so on?
    When I look at my clients history of cost those darn drugs really drove cost wonder how that effected Medicare…oh that’s right Medicare didn’t even cover Rx until 2006.
    “If the ACA is allowed to take effect, Medicare will be even more effective at that.”
    Really Pat? Because the title of the bill says so or what is this based on? Every time Congress “reforms” healthcare and Medicare its going to be more effective and efficient….oddly its never happened. If you really want to put the nail in the coffin of your argument why don’t we go back and look at Medicare cost projections since 1965….it’s destroyed every single one, the program never stays in budget and the predications for improvement never pan out.

  13. Pat –
    Payments to Medicare Advantage plans are gradually being phased down toward 100% of FFS Medicare. Yet, the two largest MA insurers, UnitedHealth Group and Humana, are highly confident that they can continue to serve MA clients in most counties. They think they will be able to offer superior benefits and still earn their target pretax profit margin of 5% over time if not in each year. They expect to do it with cost-effective networks, better care coordination and hospital discharge planning and, of course, a lot less fraud than Medicare experiences among other things. The MA program is especially popular with low income seniors and participation, currently at 25% of Medicare beneficiaries, is likely to keep increasing, albeit gradually.
    At the same time, as the states deal with their own budget issues, they are moving more and more Medicaid beneficiaries into managed care plans because they save money.
    The higher contract rates extracted from private insurers by powerful hospitals and large physician groups are largely attributable to cost shifting as these providers claim that Medicare and especially Medicaid don’t pay them enough to cover their costs. To counteract this, tiered network, narrow network and limited network insurance products are finally starting to gain traction with employers. The concept is particularly well established in CA. These products are significantly cheaper than the broad network insurance plans are.
    While some procedures and cases are paid adequately by Medicare, many are not. It’s inconceivable to me that dictated prices can strike a reasonable balance between supply and demand in all geographic markets and for all procedures over time. If there were no private sector to shift costs to, it’s likely that care generally would be less accessible for many. As for Medicaid rates, everyone knows they are far below costs. There is a limit to how much and how far you can squeeze providers with dictated prices.
    As we get ready for the implementation of exchanges in 2014, insurers will have to offer benefit plans with actuarial ratings of between 60% (Bronze) and 90% (Platinum) with a rating of 100 defined as covering all healthcare costs expected to be incurred by a standard population. My understanding is that current FFS Medicare has an actuarial rating of less than 60 yet it still can’t control its costs. Private sector premiums are influenced not only by new mandated benefits as Nate suggested but also by changes in the average age and health status of its insured population. Increasing costs per procedure are a factor but there are a lot of moving parts here.

  14. Barry and Nate –
    The charge premiums extracted from private insurance by providers are completely unrelated to Medicare, but rather are typical of pricing obtained by suppliers in any industry who are able to extract premium prices by virtue of market power, whether they are Apple or the Harvard Affiliated hospitals. The notion of cost shifting as a significant factor is a constant propaganda trope on the part of providers and private insurers, but is largely not real. Almost half of hospitals actually make a profit on Medicare, including many for whom Medicare and Medicaid provide the great majority of their income, and hospitals actually make a profit on well over 75% of Medicare patients. Relatively minor adjustments to management could convert most hospitals’ Medicare management accounts into the black, as illustrated by experiments such as the Essentia congestive failure project.
    The gap between Medicare and private insurance this year was not due to an increase in the price growth of private insurance, which progressed at a more or less typical rate of inflation compared with past years (except for the private insurance Medicare Part D program, which grew by a spectacular 11% but is not counted in the data for private insurance,) but by the much lower rate of growth on the part of Medicare. Medicare cost growth has been slower, often substantially slower, than private insurance, for almost the entire history of the program, the only exceptions being the first few years, when Medicare rates were explicitly tied to the Blue Cross/Blue Shield rate by the original law, and for the period in the 90′s when adoption of managed care techniques drove private insurance cost growth below Medicare for a few years.
    As Barry notes, some Medicare Advantage programs are worth the premium price, especially those run by the large HMO’s in some enclaves on the West Coast, where truly superior results are attained. Many programs however are not worthwhile. In my area of the country, there is at least one very popular MA program run by a very large private insurer that succeeds by using part of the premium payment from the government to reduce enrollee prices below FFS Medicare, but actually makes its system work by also greatly reducing service, a fact that becomes clear to enrollees only if they have the misfortune of having to make claims.
    As I noted, claims that private insurance experiences less fraud than Medicare have, to date, not held up in any objective studies, although objective studies are rare because of the unwillingness of most private insurers to provide access to their data. However,ask yourself two questions. First, when was the last time you heard of a private insurer exposing an instance of fraud or prosecuting fraud? Second, isn’t Naomi’s experience — a provider billing for a service and a product that was not needed — actually an instance of what, in Medicare, would be classified as fraud? Her private insurer, however, chose to deal with situation not by dealing with the fraud but by bouncing the charge back to Naomi. That was actually more aggressive than usual. The more typical course would have been to pay the charge and jack up the rates to cover such activity.

  15. Barry –
    Let me add that Medicare does not have uniform pricing for the country, but rather adjusts prices in virtually every community. A great deal of that work is actually contracted to private companies, with United Health Care being one of the most involved.
    I wholly agree with two of your arguments, the first being that it is completely possible for private insurers to run well designed cost-effective programs that provide high value to their customers, as they already do in Germany, Netherlands, and elsewhere with a generous helping of market regulation from the governments of those countries, and the second that prospective payment plans and cost bundling reforms by private insurance are an excellent way forward, essentially amounting to a revisit to pathways first followed by private insurance in the 1990′s. No one would be happier than me if private insurance were to introduce reforms that drove down rates of growth or even reversed cost growth, and the 90′s showed that it can be done, but that doing it would face heavy opposition by providers, some clients, and probably the media.
    I do not argue that Medicare has done an ideal job of controlling costs and know that Medicare costs have grown at rates significantly higher than inflation. Medicare could do substantially better. However, it remains true that with the exception of the two brief periods I have already discussed private insurance has done even worse, often substantially worse. That data is easily accessible to anyone who cares to look.

  16. Pat –
    Again with encouragement from some of the large, self-funded employers, insurers are starting to reimburse out-of-network providers in some markets at a flat 110% of Medicare with the provider then allowed to balance bill the patient for charges beyond that. As a by-product, this will also greatly improve price transparency with respect to these providers for both referring doctors and patients. If what you say about most hospitals being able to drive their Medicare revenues into the black with some minor adjustments is accurate, it will be interesting to watch them try to explain to younger, commercially insured patients why they should be expected to pay the difference between 110% of Medicare and 200% or 300% of Medicare or even more. If they resort to heavy handed collection tactics, the media should have a field day in exposing them.
    It is only very recently in most parts of the country that what I consider to be market forces are starting to gain traction as employers become increasingly exasperated with the rising cost of health insurance and employees come to understand that those rising costs are crowding out their employer’s ability to give them a decent pay raise. These trends include tiered networks, narrow networks, limited networks, bundled pricing for surgical procedures, greater use of capitated payments and, as I noted above, payment to out-of-network providers based on a flat percentage above Medicare. It’s possible to create countervailing power against hospitals with a well known brand name or a significant local or regional market share and we’re finally starting to see it. It’s about time.

  17. Barry –
    That is great, and a major step in the right direction.
    Even better would be if insurance companies started to offer programs that paid something like 115% of Medicare to all comers — a number I chose because it is the number that hospital organizations like to claim is the average collection from private insurance and also is the premium that Medicare Advantage has averaged. That would obviously put the onus of instituting health care savings on Medicare, since the private insurers would be shadowing Medicare, but with attention to approaches like the IPAB.
    And for an even better step, let’s suggest that someone pick up what the ACA proposes for the insurance exchange — listing charges and benefits for all insurance programs and explaining benefits in a concise way, including explaining that if you want to go to your regional Taj Mahal medical center you will have to pay a premium that is 80% higher than if you are satisfied with the hospital and clinic down the block.
    Private insurance can be more efficient than Medicare and provide excellent benefits — we know this because they did it for a few short years in the 90′s. They could do it again, if they find the courage, but to do it successfully they are going to have to educate the public so they understand what this is all about.

  18. Just to provide some concrete data on the subject of health insurance fraud data and the relative performance of private and public sector insurers.
    The insurance industry organization Coalition Against Insurance Fraud reports data on various aspects of insurance fraud periodically. The last article from them on health care insurance fraud I found is from 2009 and reports data from 2007.
    Here are their results for health insurance fraud:
    Total health insurance fraud: $68 billion.
    Medicare insurance fraud: $10.8 billion.
    Medicaid insurance fraud: $12.9 billion.
    Private health insurance fraud: $44.3 billion.
    The report goes on to note that 20% of private insurance claims processers did not have computerized or other extensive anti-fraud systems in place, and to urge them to adopt them as soon as possible, arguing that the systems would pay for themselves in savings from detection of fraud.
    These data are obviously slightly outdated, but I have every confidence that there has been no significant change in overall trends except that as health care spending has increased the dollar amounts of fraud have increased. I would also expect that the crash of 2007 has accelerated incentives to commit insurance fraud, as with all money motivated crimes. In fact, here in remote Northern Minnesota the largest regional health care organization has recently started requiring photo ID at check in for all adults because of experience with patients attempting fraudulent use of other people’s insurance.
    The Coalition report also notes that the numbers reported do not include another type of “insurance fraud,” companies set up in some parts of the country to sell health insurance programs that are either flat out fraudulent or that provide such poor benefits as to be effectively fraudulent. The organization urges its member companies to push state insurance boards to adopt regulations to prohibit and police such companies in order to protect the position and reputation of legitimate health insurance companies.
    One additional note from me: a substantial amount of Medicaid “fraud” is due to people in borderline income categories understating their income in order to qualify for Medicaid. That means that in a state where the income ceiling for Medicaid is $7000 a year, a single mother who understates an income of $7500 a year to qualify is committing fraud. The noted conservative economist Glen Becker once commented on this form of “fraud” by urging that states spend less effort catching people in that kind of situation and more effort catching fraudulent claims by providers and suppliers, saying that at worst the situation involved poor people getting health care they would otherwise not be able to get.

  19. Is this true? i think you are doing a pretty awesome job by sharing such facts with general public. as we people are unaware of all such facts. thanks

  20. Thanks for all the comments, I have gained some real insight into how the coding issue is really much bigger than just an issue of disparate and error-plagued systems. Pat S. thanks for doing the research to find this report on fraud in the private insurance market–we do hear a lot about Medicaid and Medicare and it’s interesting to find out that fraud is just as prevalent in the private sector.Will have to look into this more. Although, I have to admit that I’m not surprised; I have witnessed “up-coding” and a wide range of other direct attempts to “game” the private insurance system. I never quite understood why my GP insisted on having his nurse drag in a portable EKG machine and also administer a “blow” test at every visit–even for a sore throat. It seemed that they could stay ahead in the game just by regularly charging for these services and take what what they could get in reimbursement.
    But what strikes me is that at the micro level (as we’ve said hundreds of times before)there is a significant amount of waste, fraud and poor organization that adds up to a considerable drain on health care costs. This exchange of comments just makes that more clear to me.

  21. This is terrible news for people stuck in such a terrible economy we’re all having right now. I hope a better solution will come about in the coming months.

  22. You’ve hit a nerve on this post, especially when I read “a billing clerk per bed. It’s obscene”. I constantly deal with these problems from my error prone 8 yr old into emergency rooms to my 77 yr old father in a nursing home. I don’t know how many hours I’ve wasted “Resubmitting the same description of his accident to the insurance policy 3 times” to only receive the same form 3 weeks later asking for the accident description. I also bought an accident only policy from a local public school to prevent me having to pay any part of my deductible if my son accidently hurts himself.
    In theory this was a good buy, but they have yet to pay for his PVC pole vault incident of his grandparents air conditioner. The hospital’s billing clerk is now actively chasing down this insurance policy to pay.
    As you know, Google Health, shut down recently because they couldn’t get any kind of standardized system in place to load medical records. What the government did to accounting with GAP practices decades ago needs to happen to the healthcare system. We need standard forms and billing. It would save everyone time.
    On a side note, I would love to exchange links with you on my “Medical Noise” blog. Let me know how you want the text to be listed and get back with me.

  23. “Among the assorted charges not covered by our insurance was $218 for a “short leg splint calf to foot.” As I mentioned, we left with a “shoe” that consisted of an inflexible sole held in place by Velcro straps—definitely not a “short leg splint.”
    As you know, the description of the device is attached to the CPT code they chose….since the CPT manual doesn’t include pictures, and doesn’t include a code for every device on the market, often the provider simply guesses at the description that sounds the closest.
    Tell them they picked the wrong L code — you didn’t get a fracture boot, you got post op shoe — and you’ll give them 110% of their cost, which should be about 15 bucks.

    • Tara,m

      Yes. We are the only country in the developed world that has decided to let health care become a largely
      unregulated for-profit business.
      In other countries, the government pushes back to protect consumers. It tells drug companies: no we’re not going to pay that much for this new drug you want to bring to market: there is no medical evidence that it is that much better. Governments negotate hospital rates and
      doctors’ fees.
      In the U.S. in theory “free market competition” will set prices, but in practice, that doesn’t work very well when it comes to healthcare.
      Patietns don’t have much leverage. They can’t say “I’ll wait until prices come down before I buy.” IF they need treatment, they need
      treatment. And, since they are not medical researchers and have not been to medical school, they are not in a good position to compare
      products or services and feel confident that they know which one is better.
      Finallly, they tend to assume that the most expensive product or service is better–which often isn’t true.

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