Post Procedure Billing Health
Undergoing a medical procedure can be a significant step toward improving one's health and quality of life. However, the financial aspect of healthcare often leaves patients with questions and concerns, particularly when it comes to post-procedure billing. Understanding how medical costs are calculated, what is covered by insurance, and how to handle unexpected charges is essential for a stress-free recovery.
30 Days after discharge
Bills should be arriving from the hospital and the physicians for your hospital date of service.
Review the bills and put them into two piles, doctors, and hospitals for better understanding. If your bills are statements and not detailed with line item details, call your billing office at the hospital and request a copy of the “Detailed Bill” from their system that shows every item you were charged for during your stay.
You should have received an EOB (explanation of benefits) from your insurance company for this hospital stay.
Did you get your copy of your medical records that you requested at the hospital? Does it have the following items?
Admission H&P (history and physical)
Operative note
Discharge note
All lab/pathology test reports, radiology studies reports, EKG reports these will be used for both hospital and physician bills verification
Orders that were placed during your stay at the hospital
Operating room record
Anesthesia record
Copies of implantable items UPC stickers with make model of the item
Reviewing your bills
The key to reviewing your bill is understanding what you are being billed for.
Hospitals bill for expected/ordered services or standing orders which are order sets that are always done when on arrival in the Emergency Room. Often, they will not appear on the order sheet. Standing orders have been pre-approved by the Medical Staff committee before being approved by the hospital.
Example: arrive broken arm, standing order is X-ray for the broken bone, usually a 3-view image
Example: arrive with chest pain, labs, EKG, baby aspirin 350mg, and nitroglycerin if still having chest pain
Physician bill for the surgical work performed, or hospital visits while a patient i.e.: hospitalist or emergency room physician or specialist brought in to consult on your case.
Ancillary bills from physicians are for review and report of services performed by them in radiology, pathology, cardiology etc.
Auditing of your hospital bill
Auditing requires a level of understanding of reading and associating charges from the detailed bill to the documentation from your medical record
By knowing what to look for based on departments within the hospital you will be better able to review the charges. An example:
Lab charges, each order in your medical record should have a corresponding report in your medical record. That report then corresponds to a charge on your detail bill. Please be advised that you could have multiple tests on the report to correspond to the billed charges.
Pharmacy products are hard to keep track of and you could look at the MAR (Medicine Administration Record, Emergency room record, Anesthesia record so they could be located in multiple areas.
Radiology orders should have a corresponding report that then corresponds to the charge on your bill.
IF THE ORDER DOES NOT HAVE A REPORT OR SHOWS THAT IT WAS PERFORMED (PHARMACY ITEMS) THAN THE SERVICE WAS NOT PERFORMED AND SHOULD NOT HAVE A CHARGE ON YOUR BILL
Medical records will have an “abstract” or a corresponding report that says these are the diagnosis codes when you were admitted, these are the CPT codes for the procedures they performed, and these are the final diagnosis at discharge. This is KEY information to have especially if you end up doing an appeal.
As will all things audit, you may find items in the medical record that were ordered and performed that did not get charged to you. That is an error on the hospital’s part. We report the good with the bad as human beings are entering documentation.
Auditing the physician bills
With having gotten your medical record from the hospital your physician notes and orders are at your fingertips
All reports from pathology, radiology, emergency room, operating room, discharge, room visits or consults in the hospital are in your hospital medical record. They will not be in your physician office medical record.
The reports are important because they will give your final procedure and final diagnosis based on the findings from surgery and pathology reports. Anything they remove from your body goes to pathology for it to be reviewed by a pathologist so that documentation is key.
To audit you take each physician bill and make a list of doctors to what they specialize in, example:
Dr Smith orthopedic surgeon
Dr Jones anesthesiologist
Dr Frank pathology
Once you have your bills listed then go to your medical record and find the reports they performed. If a cardiologist sent a bill, then look for your EKG or other cardiac test. If a pathologist billed, look for a lab pathology report, etc. We want to make sure that we have documentation for every physician billing within your medical bill.
If you find a physician billed you but you have no documentation, call the number on the bill and tell them you have reviewed the documentation and you want a copy of their report for the bill. They may ask for a release of medical records, that’s appropriate and do that.
Or you can tell the physician office that you want your bill reviewed as there is no evidence that the physician saw you and you think it's an error in billing. They have nurse auditors in these billing offices that will review and call you back.
Reviewing your insurance explanation of benefits
You have by now received at least one statement from your insurance company
If you are Medicare, you may have received a Part A statement for your Inpatient hospital stay and a Part B for your outpatient stay and physician bills.
If you have commercial insurance, you will receive a single statement covering every billing entity in one statement. Regardless of whether you were an Inpatient or Outpatient.
Each individual entity that billed the insurance will have a section with explanations as to what was billed by CPT code, with the charge the entity billed, the amount the insurance recognizes as usual and customary for that service, the amount not allowed to be paid, the amount that the patient is responsible for and the amount written off by the entity. Example:
Hospital charges
99284 ER visit
Hospital charged $1000
Insurance says usual is $450
Not allowed is $550
Patient responsible for $200 as part of deductible
Insurance pays $250
Hospital writes off $550 as contractual and cannot bill this to the patient
You will see message codes, usually two numbers or two letters and a number, these codes are defined within the statement at the end of that entity’s portions. These will tell you additional information having to do with payment, denial, and hence the name “reason codes”.
What becomes difficult is trying to make sure that you can match the entity (hospital or physician) to the sections that are for them. You may want to make a copy of the EOB and then have the copies to attach to the individual bills to keep better records.
You will get a provisional statement from insurance based on the hospital getting their billing into the insurance within 10 days of discharge. Most insurance won’t pay until they get physician bills due to the coding match that is used for payment. Physician diagnosis codes order and hospital must match. As well as the CPT codes billed for procedures in surgery or at bedside when an inpatient.
Final EOB statements will come once all physician bills are in and you may see denials due to physicians not billing correct codes based on the hospital.
Appeals are not for the faint of heart!
You’ve been denied by the insurance company for payment. What do you do?
Let’s look closer at what the denial is about.
Is the denial based on a single item in the list of items billed?
Is the denial on the whole claim?
What does the reason code say about the denial?
Is this the physician or hospital bill or item being denied payment?
Denials can be tricky because they can mean so many things depending on what it says.
If your denial is for the physician bill, call to speak to the billing department. Tell them you received a denial and want to discuss why you were denied and what “they” are going to do to fix this. Do not take responsibility for the denial. They need to work with the insurance, not you.
Capture the person’s name, time of call, reason to call, and outcome of the call. Documentation is key to getting the right answer. Develop a log for all calls as you may get different answers from different people, and you want to make sure you have proof of what was said.
If the denial is for the hospital, call the business office and ask to speak to a person in Denial Management about a claim issue you have. This section of the business office deals with denials of all kinds and will be better able to answer your questions. Again, do not accept responsibility for doing and appeal. This is their responsibility to get to the bottom of the denial and fix the problem, NOT YOU.
If there appears to be no recourse with the billing people of the entity, then contact your insurance company and ask to speak to a denial processor about the denial of your claim. Remember to get the name of the CSR, date/time of call, what was discussed and keep this info in your log.
Follow their directions as they may give you things to do like getting a corrected copy of a physician diagnosis or procedure code rebilled to them. Or they could say that they are paid for the greater procedure, and they billed a charge that is not separately billed and is included in the first charge. If you don’t understand what they want, write it down. I will explain why.
What if you just are too confused and want to throw your hands in the air and quit and pay it to get it off your to do list.
DON’T DO THAT!!! This is your money, your emotional and physical health we are talking about and this will not fix the problem.
Call Tricky Bills Call Center and talk to one of our expert staff about your situation. You have done 50% of the work already, let's use that work and together get you and your healthcare responsibilities taken care of.
Start with a 15 min call to briefly discuss the issue and let the consultant help you to formulate a plan.
You have all the documentation so lets upload it into Tricky Bills so that your consultant can review the documents,
Detail bill from the hospital
All physician bills
Medical Records
Copy of your insurance card
My recommendation is to perform an audit. Not that you did it wrong but so an expert can review everything and verify your work was correct or give you news that perhaps we found more items that need to be removed from your bill.
Once the audit is complete lets do another call and we can review the details together and start looking at why you were denied, and the best place to start getting everything corrected.
We can give you step by step instructions on next steps and you can proceed on your own better educated and more prepared to get the positive action you want
Or we can help with being on calls with you to your insurance or hospital or doctors billing offices to listen and comment helping you to get the information and results you need.
Not everything ends in a win win. Sometimes the pre-procedure had holes in it and therefore the post-procedure bill is not what we expected. Tricky Bills will do its best to provide you with the guidance and personal assistance to have that positive outcome you believe you are entitled to.
