Medical Billing question

Questions on how we spend our money and our time - consumer goods and services, home and vehicle, leisure and recreational activities
Post Reply
Saving$
Posts: 1518
Joined: Sat Nov 05, 2011 8:33 pm

Medical Billing question

Post by Saving$ » Fri Oct 27, 2017 2:17 pm

A family member changed doctors, which resulted in a change in provider eco-systems, lets say from Old to New

New doctor directed my family member to get her annual mammogram at the New facility associated with the hospital group with which the new doctor is associated. When my family member tried to make the appointment, they told her she had to get her historical results from Old (many years of mammo's) to New before she could make an appointment. Old told her they would not transfer them without her personally appearing with ID, signing a form, it would take about 2 hours, and they don't transfer anything without a personal appearance unless it is an emergency. Due to the necessity to take off of work, she put this off, and started receiving messages from the New mammo center and doctors office that she was past due for her annual checkup. During one call, the rep from New stated they could obtain the records from Old with no problem, and she should make the appointment, and bring the signed transfer authorization to the appointment, which she did.

Shortly after the appointment, New mammo center called and said they needed to schedule a follow up. She did not question this, as she reports it happened every few years when she was receiving them from Old, and she never once received any type of invoice or bill for this follow up. At her follow up appointment at New, which was only a few days after her initial appointment, they used a different machine, and after the procedure had her meet with a mammo doctor (not her PCP). This doctor stated that without comparing to historical data, she could not say if anything was wrong, and she wished they had waited to receive the data from Old before they brought her back in for the follow up. Doctor told my family member they would wait for the data from Old, compare and let her know. Within a week she received a letter that all was ok.

Three weeks later she received two invoices from New; one for the imaging, one for the doctor appointment. These invoices total close to $500, so it is not insignificant, but won't irrevocably break her financially either. Calls to New get her nowhere -New insists the follow up is not covered under the free annual mammograms, that the follow up was necessary, and that they have no record of their doctor stating the follow up appointment was premature, and it is not their responsibility to make that determination, and they have no idea why she thinks she would not be charged for a follow up.

She totally does not think she should have to pay anything, since annual mammos are free, she was never billed for follow ups at Old (although she also never met with a mammo doctor at old), and New never told her there would be a cost. Although she likes her new PCP, she thinks their mammo center tried to make money off her on what she now thinks is unnecessary work.

She asked me what I thought. Legally I think she probably signed something agreeing to pay anything insurance does not. Business wise, I think each side probably had totally different expectations and neither probably communicated well about expected cost or lack thereof. But I have no idea if this is a fair billing or they are taking advantage of her, and if there are, if there is any chance of fighting it. How should this $500 be resolved?

goodlifer
Posts: 199
Joined: Sun Aug 16, 2015 9:50 pm

Re: Medical Billing question

Post by goodlifer » Fri Oct 27, 2017 2:39 pm

You have a multi-layered problem here. First, did she get a 2D or 3D (or digital) mammogram? Some insurance companies don't pay 3D 100% and some breast centers only have 3D. There may have been extra cost with that. Some one could have also used the wrong billing codes and it wasn't viewed as a routine mammo. A similar problem could have occurred with the follow up visit. It could have been a routine visit and was billed as something more involved. Because it seems to be the office's fault for the follow up mix up, they should accept what the insurance paid and write off the balance. The doctor deserves to get paid, and in all fairness, your family member was already told how to get the historical data and it wasn't done as instructed. There is a chance they won't feel the need to write anything off. I'm sure she signed the contract stating she is responsible for paying the balance, but it has to be the correct balance. Get the EOB's and bills together, and ask for help from both the insurance company and the breast center to determine the correct amount she owes.

runner3081
Posts: 781
Joined: Mon Aug 22, 2016 3:22 pm

Re: Medical Billing question

Post by runner3081 » Fri Oct 27, 2017 2:41 pm

It is very common for follow-ups to preventive appointments to be billed. It is very possible that the old practice has more friendly billing practices and did not charge this, or simply took that the insurance paid for the visit and did not bill a balance.

New company may be more "by the book" to maximize revenue.

User avatar
flamesabers
Posts: 1470
Joined: Fri Mar 03, 2017 12:05 pm
Location: Rochester, MN

Re: Medical Billing question

Post by flamesabers » Fri Oct 27, 2017 2:45 pm

Why did the new hospital call her in for a follow-up screening before getting the historical data from her prior screening? Why did the new hospital have her meet with a specialist doctor instead of her PCP (only to be told there is insufficient data to make a determination)?

What does her health insurance carrier say in regards to paying for mammogram screenings? Does her insurer only cover 100% of one annual screening and any follow-up appointment is billed to the patient?

To me it sounds like the problem is both parties made too many wrong assumptions then anything else.

User avatar
Flobes
Posts: 831
Joined: Tue Feb 16, 2010 12:40 am

Re: Medical Billing question

Post by Flobes » Fri Oct 27, 2017 3:08 pm

Saving$ wrote:
Fri Oct 27, 2017 2:17 pm
...she received two invoices from New; one for the imaging, one for the doctor appointment. These invoices total close to $500... New insists the follow up is not covered under the free annual mammograms, that the follow up was necessary, and that they have no record of their doctor stating the follow up appointment was premature, and it is not their responsibility to make that determination, and they have no idea why she thinks she would not be charged for a follow up.

She totally does not think she should have to pay anything, since annual mammos are free, she was never billed for follow ups at Old (although she also never met with a mammo doctor at old), and New never told her there would be a cost. Although she likes her new PCP, she thinks their mammo center tried to make money off her on what she now thinks is unnecessary work.
I've enjoyed many a routine mammo, free as part of annual wellness coverage. Through the decades, I've had a number of call-backs.

The follow-up always results in two bills: one for imaging and one for MD radiologist who reads the imaging. Stated as inverse: a follow-up has never been covered as part of routine check-up.

However, I've never actually paid for the follow-ups because:
* I was beyond my deductible (when I was on health insurance), or
* Quite recently, it was covered by Medicare, or
* It was paid by our local Komen organization, pre-arranged as advised by facilities scheduler when I asked about costs.

Zott
Posts: 208
Joined: Fri Jul 31, 2015 10:21 pm

Re: Medical Billing question

Post by Zott » Fri Oct 27, 2017 9:49 pm

Whatever the outcome, your family member should be prepared for it to happen again next year.

toofache32
Posts: 1006
Joined: Sun Mar 04, 2012 6:30 pm

Re: Medical Billing question

Post by toofache32 » Fri Oct 27, 2017 10:46 pm

I'm confused. Are you expecting the follow up visit to be for free?

Saving$
Posts: 1518
Joined: Sat Nov 05, 2011 8:33 pm

Re: Medical Billing question

Post by Saving$ » Sat Oct 28, 2017 7:48 am

goodlifer wrote:
Fri Oct 27, 2017 2:39 pm
First, did she get a 2D or 3D (or digital) mammogram? Some insurance companies don't pay 3D 100% and some breast centers only have 3D. There may have been extra cost with that.
She has no idea. Is there a way to check that on the billing? She says the follow up was on a different machine, and near the end the tech mentioned it is the only machine like it in the state. She remembers hoping her follow up was not related to their need to pay for the machine.
goodlifer wrote:
Fri Oct 27, 2017 2:39 pm
Some one could have also used the wrong billing codes and it wasn't viewed as a routine mammo. A similar problem could have occurred with the follow up visit. It could have been a routine visit and was billed as something more involved.
Insurance paid for the first, just not the follow up
goodlifer wrote:
Fri Oct 27, 2017 2:39 pm
Because it seems to be the office's fault for the follow up mix up, they should accept what the insurance paid and write off the balance.
Somehow the follow up is not part of the annual mammo screening considered preventative, so it is being billed. She has not met her deductible, so after the provider applied the insurance "discount" the entire amount was billed to the patient.
goodlifer wrote:
Fri Oct 27, 2017 2:39 pm
The doctor deserves to get paid, and in all fairness, your family member was already told how to get the historical data and it wasn't done as instructed.
This is somewhat incorrect. She was not going to make the appointment until she had the historical data, but the imaging center all of a sudden stated they could get the data themselves, with a form. The is why she moved forward.
goodlifer wrote:
Fri Oct 27, 2017 2:39 pm
There is a chance they won't feel the need to write anything off. I'm sure she signed the contract stating she is responsible for paying the balance, but it has to be the correct balance. Get the EOB's and bills together, and ask for help from both the insurance company and the breast center to determine the correct amount she owes.
This seems to be where she is - New feels no need to write it off, the insurance won't count it as standard mammo that is free every year, so she is left paying
flamesabers wrote:
Fri Oct 27, 2017 2:45 pm
Why did the new hospital call her in for a follow-up screening before getting the historical data from her prior screening?
Good question; she says she assumed it was like all the other times she was called back. They redo a few of the images and that is the end of it.
flamesabers wrote:
Fri Oct 27, 2017 2:45 pm
Why did the new hospital have her meet with a specialist doctor instead of her PCP (only to be told there is insufficient data to make a determination)?
I asked the same thing. She says after the procedure they told her to go into a certain room to wait, and the doctor came into that room.
flamesabers wrote:
Fri Oct 27, 2017 2:45 pm
What does her health insurance carrier say in regards to paying for mammogram screenings? Does her insurer only cover 100% of one annual screening and any follow-up appointment is billed to the patient?
This seems to be the crux of the issue- she thought the follow up was part of the annual screening as it had been at the old facility, and the new facility is apparently billing it different, as something else.

toofache32
Posts: 1006
Joined: Sun Mar 04, 2012 6:30 pm

Re: Medical Billing question

Post by toofache32 » Sat Oct 28, 2017 10:38 am

runner3081 wrote:
Fri Oct 27, 2017 2:41 pm
It is very common for follow-ups to preventive appointments to be billed. It is very possible that the old practice has more friendly billing practices and did not charge this, or simply took that the insurance paid for the visit and did not bill a balance.

New company may be more "by the book" to maximize revenue.
This is very common. A similar tactic is to not collect copays and only take what insurance pays, which is actually insurance fraud.

Saving$
Posts: 1518
Joined: Sat Nov 05, 2011 8:33 pm

Re: Medical Billing question

Post by Saving$ » Sun Oct 29, 2017 2:47 pm

So bottom line - should she be more insistent that they not bill her for this, or should she pay it, or other?

runner3081
Posts: 781
Joined: Mon Aug 22, 2016 3:22 pm

Re: Medical Billing question

Post by runner3081 » Sun Oct 29, 2017 3:12 pm

Saving$ wrote:
Sun Oct 29, 2017 2:47 pm
So bottom line - should she be more insistent that they not bill her for this, or should she pay it, or other?
Inquire, but ultimately, pay it.

User avatar
flamesabers
Posts: 1470
Joined: Fri Mar 03, 2017 12:05 pm
Location: Rochester, MN

Re: Medical Billing question

Post by flamesabers » Mon Oct 30, 2017 9:03 am

Saving$ wrote:
Sun Oct 29, 2017 2:47 pm
So bottom line - should she be more insistent that they not bill her for this, or should she pay it, or other?
I agree she should pay this off. In your initial post you said she probably signed something in which she agree to pay whatever insurance does not. While the new hospital could have handled this matter in a less clumsy manner, I think patients still have burden of the due diligence to ask questions instead of assuming insurance will cover everything.

Rupert
Posts: 2670
Joined: Fri Aug 17, 2012 12:01 pm

Re: Medical Billing question

Post by Rupert » Mon Oct 30, 2017 9:39 am

Saving$ wrote:
Sun Oct 29, 2017 2:47 pm
So bottom line - should she be more insistent that they not bill her for this, or should she pay it, or other?
Yes, she should pay it. What the new practice did was typical and likely correct. Screening mammograms are included in preventive services and are free to the patient. The images made during a screening mammogram usually aren't read by a radiologist on the day of the exam; they'll be read, and a report prepared, later, usually within a week or two. If an issue is detected on the screening mammogram, then a callback occurs. During the callback, new screening is performed (maybe a repeat 2D mammogram, maybe a 3D mammogram, often an ultrasound), and a radiologist has to read those images immediately. The radiologist is reading the images as they are taken (and is often directing the technician's actions from another room) and sometimes will perform the ultrasound himself/herself. So the callback is very much an appointment with the radiologist, not just a diagnostic test. It is not unusual for the patient to actually meet with the radiologist to discuss the new images and any possible diagnosis. What the old practice did (not billing her for followup) was unusual, IMHO.

PoppyA
Posts: 353
Joined: Sat Oct 11, 2014 4:24 pm

Re: Medical Billing question

Post by PoppyA » Mon Oct 30, 2017 10:17 am

Definitely a money maker for the facility. My place tried to pull this until I demanded that the X-rays be read immediately after they were taken. At my facility (a stand alone site attached to a larger medical clinic, which is pretty much the norm now) I KNOW the radiologist sit around in the back of the facility reading books when they are not too busy!

I’d pay this time but talk to the manager about how to prevent it in the future.
"La Bella Luna"

Rupert
Posts: 2670
Joined: Fri Aug 17, 2012 12:01 pm

Re: Medical Billing question

Post by Rupert » Mon Oct 30, 2017 10:56 am

PoppyA wrote:
Mon Oct 30, 2017 10:17 am
Definitely a money maker for the facility. My place tried to pull this until I demanded that the X-rays be read immediately after they were taken. At my facility (a stand alone site attached to a larger medical clinic, which is pretty much the norm now) I KNOW the radiologist sit around in the back of the facility reading books when they are not too busy!

I’d pay this time but talk to the manager about how to prevent it in the future.
No offense, but this is very bad information. The screening mammogram is a preventive service that the ACA requires to be covered 100% by health insurance. A followup mammogram (or a mammogram performed because a woman reports a lump in her breast, etc.) is not preventive. It's diagnostic, meaning it's performed because the doctor suspects the patient suffers from a disease or defect of some sort. As such, it falls under the diagnostic testing provisions of your health insurance contract, which typically require co-pays, deductibles, co-insurance, etc. If a facility performs a diagnostic mammogram and bills it as a screening mammogram, that's insurance fraud. You can't mix the two together as you suggest in your post. Typically, if a woman shows up at a breast center for her screening mammogram and reports that she presently has a lump in her breast, the center will re-schedule the mammogram on a different day as a diagnostic mammogram. They won't even do a screening if the woman reports an actual breast issue.

InMyDreams
Posts: 144
Joined: Tue Feb 28, 2017 11:35 am

Re: Medical Billing question

Post by InMyDreams » Mon Oct 30, 2017 11:31 am

Saving$ wrote:
Fri Oct 27, 2017 2:17 pm
This doctor stated that without comparing to historical data, she could not say if anything was wrong, and she wished they had waited to receive the data from Old before they brought her back in for the follow up. Doctor told my family member they would wait for the data from Old, compare and let her know.
Is this a stand alone imaging facility, or part of a big hospital facility? You could try contacting patient relations, explain the circumstances, and see if they would discount the bill further.

It also makes no sense to me that the old facility would release only to someone standing at the counter. What if she had moved out of state? Too late now to rock the boat, but I would have called patient relations about that one.

User avatar
flamesabers
Posts: 1470
Joined: Fri Mar 03, 2017 12:05 pm
Location: Rochester, MN

Re: Medical Billing question

Post by flamesabers » Mon Oct 30, 2017 1:07 pm

InMyDreams wrote:
Mon Oct 30, 2017 11:31 am
It also makes no sense to me that the old facility would release only to someone standing at the counter. What if she had moved out of state? Too late now to rock the boat, but I would have called patient relations about that one.
I suspect the policy is intended to protect the privacy of their patients as well as to minimize the risk of getting sued for improper handling of a patient's medical records.

Katietsu
Posts: 849
Joined: Sun Sep 22, 2013 1:48 am

Re: Medical Billing question

Post by Katietsu » Mon Oct 30, 2017 1:10 pm

You can always try to negotiate. However, if she has to pay, the other way to look at it is that there was something suspicious on the first image that required specialized follow up. If the imaging center had not scheduled the follow up, the old records were not received, the patient never returned assuming it was OK, and there had been cancer present then this conversation would be about whether or not malpractice had occurred. Also, just because they wanted the old records before giving a conclusive answer does not mean that the second imaging might not still have been recommended had the old records been received first. Finally, I suspect there are very few facilities with schedulers adept enough to try to rack up unnecessary testing in this way even if there was a new piece of equipment to pay for.

Post Reply