With the Affordable Care Act came many changes to covered medical services and access to care. While there are a million different opinions about the ACA or Obamacare, I think we can all agree that health care has not gotten any easier to understand. I work in health care and get surprised almost every week by some new twist in insurance billing and coverage. It’s important as a consumer to understand your insurance policy and know how to dispute a medical bill if errors were made. I got a refresher course recently when I had a doctor visit billed incorrectly, so I though I’d share my experience.
What Is Covered with the ACA?
If you have an ACA compliant plan (if you don’t, it probably got cancelled), there are several medical services that are covered without copays, co-insurance, or deductibles if you use a network provider. This applies to any policy, regardless of deductible. Some of these include:
An Annual Physical- Includes screening tests appropriate for your age and risk factors, like mammograms, PSA tests, or diabetes and high blood pressure screenings.
Well Child Visits
You can read the entire list at Healthcare.gov
My “Free” Physical
I went for my annual physical in April. I don’t take any chronic medicines other than birth control. This appointment was mainly to renew that. The doctor asked about labs for cholesterol and triglyceride screenings, and I told her I would be doing those at the upcoming health fair. All of this fits into the definition of routine physical.
At the end of the exam, I brought up an issue I’d been having. I’m a bit embarrassed to say that after a really turbulent flight last year, I now experience anxiety when flying. It’s not crippling. I haven’t needed a straight jacket, but it can be uncomfortable, especially with a 7 year old to watch over. I knew we would be flying the following month and I wanted her opinion on what I might be able to do on my own or with drugs. I know lots of people take Xanax for flights, but I wasn’t sure that was a route I wanted to take.
We had maybe a 5 minute discussion and ultimately I decided to wait it out. My anxiety seems to lessen with every flight, so I didn’t want to dope myself up and take the chance I’d be incoherent.
I was surprised to get a bill this month instead of a remittance from my insurance that said they had paid for my annual physical. When I called to ask the billing department, the clerk said that the visit had been coded as Other Unspecified Phobia and was charged as an office visit. It said I owed $124 because the bill had been applied to my deductible.
How To Dispute a Medical Bill
The most important thing you can do as a medical consumer is know your insurance policy. If you don’t understand, search online. There are a million websites that can explain co-pays, co-insurance, deductibles, HSA’s, flex plans, etc. If your plan is through an employer, the HR person should be able to explain your policy. If they don’t know, ask to speak to their supervisor. Because it’s complicated is not an excuse not to know how to find answers.
I know that the purpose of this visit was my annual physical and the phobia was a secondary diagnosis that came up. I asked the billing clerk to review the claim. After transferring me to another “specialist”, I was told that they had billed the code that was sent and I needed to talk to the nurse who worked with my doctor.
It’s important to follow the steps and be polite. Yelling at a person because she billed what was sent does no good. Billing specialists have no authority to change medical records. The error was not her fault. It was also not the fault of my insurance company. They were correct not to pay based on how this claim was billed.
I then called the nurse as I was instructed to do. I explained what had happend, and her exact quote was, “I have no idea how that stuff works.” I thought that was extremely unprofessional, but I stayed polite and asked if there was someone there who might know how to correct this claim. She then got a bit huffy but said she would ask the doctor. I got a call back a few hours later that the visit had been recoded as a physical and would be rebilled.
If you know you are right, keep asking to speak with an office manager or even the doctor if staff gives you the runaround. Odds are the doctor is not going to take your call, but most of them know how the system works and are happy to fix a billing error. Everyone likes to get paid, and correct billing speeds that along. Staff are usually instructed not to bother the boss with non-medical related issues, so if you start asking to speak to the person in charge and don’t roll over if their explanation doesn’t make sense, things tend to happen faster.
Make Sure You Are Only Getting Preventative Services
It is not preventative care if you’ve been having headaches or chest pains and call to schedule your physical so you won’t have to pay to be seen for these problems. There is a list of elements the doctor must preform to bill for a service, and the code must match the chief complaint. If a routine visit is billed, it must have a routine diagnosis, like well child exam. If an office visit is billed, it must have a medical code, like headache, and is subject to deductible. If a routine visit it billed with medical code, it will be denied altogether.
At the same time you need to discuss problems you’ve been having, even if it is during a routine physical. If you are unsure how to proceed, call your doctor office and ask. If you haven’t been in in years, they might suggest a physical. If a problem is found, you’ll need to come back to address that. You can always ask your doctor during the visit as well. In my case, I probably should have said something like, “I know I’m here for my physical, but is this a good time to bring up another problem I’ve been having?”
Your doctor can tell you whether you should schedule another visit or not. It also never hurts to tell the nurse or tech that you are mainly here for a physical. The chief complaint is always recorded, so make sure you don’t start out by saying you’ve been having bad athlete’s foot or something benign, because that will go in your record. You can bring it up later if you feel it’s necessary, just don’t start out that way.
I can’t stress enough how important it is to be nice. If you don’t understand, ask. If the explanation doesn’t make sense, tell that to whoever is explaining. If you yell, swear, and threaten, people are less likely to help. If you believe you have a claim that was billed incorrectly and you’ve exhausted all options and no one will help, there are companies that specialize in auditing medical bills. This will cost money, but if you have a huge medical bill that you feel is incorrect, it might be worthwhile.
Insurance is confusing, but that is not a problem that is going away anytime soon. It’s your responsibility to try and understand it as best you can and ask questions if you don’t. It could make a huge difference when it comes to medical bills.
Have you ever had to dispute a medical bill? Do you think having a “phobia” in my record willl come back to haunt me?
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