How to Find and Correct Medical Billing Errors

Medical billing errors are a common challenge for many individuals navigating the healthcare system. These inaccuracies can range from minor discrepancies to significant overcharges. Understanding how to identify and address these errors is crucial.

Understanding and Documenting Your Bill

Identifying medical billing errors begins with a thorough review of your healthcare statements. A medical bill includes the date of service, the provider’s name, and detailed charges for procedures and supplies. Request an itemized bill from your healthcare provider.

Medical coding systems like Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) codes are key to understanding your bill. CPT codes describe medical services or procedures performed, while ICD codes specify the diagnosis or medical condition. For example, a CPT code might denote an office visit, and an ICD code would represent the reason for the visit.

Common billing errors include duplicate charges, charges for services not received, and incorrect patient information. “Upcoding” is when a provider bills for a more expensive service than provided, while “unbundling” involves billing separately for services that should be grouped. Incorrect dates of service or missing documentation also contribute to errors.

Alongside your medical bill, you will receive an Explanation of Benefits (EOB) from your health insurance company. This document is not a bill, but a summary of how your insurance processed a claim. The EOB clarifies terms such as:
Deductible: The amount you pay before coverage begins.
Copay: A fixed amount for a service.
Coinsurance: The percentage of costs you pay after meeting your deductible.
Out-of-pocket maximum: The most you will pay for covered services in a plan year.

Collect all relevant documents, including the original medical bill, your EOBs, and any medical records related to the service. Maintain a detailed log of all interactions, noting dates, times, names of representatives, and summaries of conversations. This thorough documentation provides a clear record to support your case.

Initiating Contact with the Provider

After carefully reviewing your medical bill and gathering supporting documents, contact the healthcare provider’s billing department. Many providers offer direct phone lines for billing inquiries, and some even provide online chat assistance. When you call, be prepared with specific details from your itemized bill and EOB.

Provide the bill number, dates of service, and any specific CPT or ICD codes that appear incorrect. For example, if you identified a duplicate charge for a lab test, reference the exact CPT code and date it was billed twice. You should clearly explain the discrepancy you found, whether it’s a charge for a service not rendered or an incorrect amount. Request a review of the charges and, if you haven’t already obtained it, ask for a copy of your medical record to compare against the billed services.

While phone calls can be convenient, following up with written communication, such as a formal letter, is often beneficial for documentation purposes. This creates a paper trail of your dispute and the provider’s response. Always keep a copy of any letters sent, along with notes from phone conversations, including the date, time, and the name of the person you spoke with. This meticulous record-keeping is invaluable should further escalation be necessary.

Engaging Your Health Insurance

If direct communication with the provider’s billing department does not resolve the issue, or if the error primarily stems from how your insurance processed the claim, the next step involves engaging your health insurance company. This becomes particularly relevant if your Explanation of Benefits (EOB) indicates an error not present on the provider’s bill, or if a claim was denied due to an issue with insurance processing. For instance, a claim might be denied if there was missing or incomplete information, an incorrect code was used by the provider, or the service was deemed not medically necessary.

Contact your insurance company’s member services or appeals department to initiate a review. You can start this process by calling the customer service number on your insurance card to understand their specific appeals procedure and deadlines. Most insurers require an internal appeal to be filed within a certain timeframe, often 180 days (approximately six months) from the date you received notice of the claim denial.

When filing an internal appeal, you will typically need to complete specific forms provided by your insurer and submit a letter explaining your case. Include copies of all supporting documentation, such as the relevant medical bills, EOBs, and any correspondence with the provider. Clearly state why you believe the claim should be paid, referencing your policy documents and any evidence that supports the medical necessity of the service. Your insurance company is generally required to respond to internal appeals within a set period, such as 30 days for services not yet received or 60 days for services already rendered.

Pursuing External Review and Further Steps

When internal appeals with both the provider and the insurance company have been exhausted without a satisfactory resolution, consumers have further avenues for external review. These options provide an independent assessment of the dispute, leveraging the comprehensive documentation gathered throughout the previous steps. This may involve filing a complaint with your state’s Department of Insurance (DOI) or a consumer protection agency.

The process for external review typically requires submitting copies of all relevant documents, including medical bills, EOBs, and all correspondence with both the healthcare provider and the insurer. This detailed submission allows the external reviewer to understand the history of the dispute and the attempts made to resolve it. Some states may require a non-refundable administrative fee to file certain types of disputes, which could be deducted from any amount owed if the decision is in your favor.

Maintaining persistence and organization is important throughout these escalated processes. Each external body will have its own specific forms and requirements, so carefully follow their instructions. This final level of action draws upon the complete record of your efforts, emphasizing the importance of diligent documentation from the very first interaction.