Is Your Healthcare Provider Ripping You Off?

Most people who choose healthcare as a profession do so out of a sincere desire to help others. The problem is that medicine is also a business, and occasionally, the line between good care and good business can get blurry.

This is not to suggest that doctors or hospitals are out to pad their own pockets at your expense. What we are saying, though, is that even medical providers deal with competing agendas as they try to balance providing good care with the constraints and demands of insurance companies and the desire to run a profitable business.

So how do you ensure that you are getting the best care for the best price? Be your own advocate! Though it may seem easiest to trust your health and health-related finances to your medical provider, you need to play an active role in your own care. Even if your provider is perfectly well-intentioned, mistakes can happen when it comes to healthcare and billing, and your vigilance can help keep things on track.

Here are a few steps to ensure that you are not being overcharged for your medical care:

Inquire about how your hospital visit is classified. Insurance providers vary on what they will pay for inpatient vs. outpatient care, but the way that your doctor classifies your stay makes a big difference.

To illustrate this principle, let’s say that you are insured by Medicare. Anything over two nights in a hospital should be classified as “inpatient” according to Medicare’s standards. However, sometimes doctors don’t want to appear as though they’re overcharging Medicare and will keep your status as “under observation” instead of coding your stay as an inpatient visit. The next thing you know, Medicare could deny your stay and pass a sizeable bill on to you.

Tip: Know what your medical insurance will and won’t cover for hospital visits. Ask your medical provider how they are classifying your hospital stay to ensure that it is properly covered.

Watch for in-network vs. out-of-network providers and services. Let’s say that you are in the hospital and need to be seen by a specialist. If the specialist on call happens to be out of your insurance plan’s network, it might not be covered. The same goes for blood work being sent to an out-of-network lab.

Tip: Always ask about insurance coverage when it comes to being seen by a new provider or receiving a new service (lab work, therapy, testing, etc.) Stay confident—you may find resistance to your questions or simply feel like doctors and staff are too busy to provide answers, but you have the right to ask questions and receive informed answers.

Check prescription charges. When it comes to prescription drug coverage, formularies change—sometimes quite often. Your insurance company may suddenly announce that they will no longer pay for a medication that you have been taking (and they have been covering) for years.

Insurance companies update their formularies yearly, but they can also make changes throughout the year if a new drug, or a generic version of an existing drug, becomes available or if the FDA changes the status of a drug.

Tip: Reviewing your drug formulary annually is a good first step. If you’re denied a drug that should be covered, talk to your doctor. You may need to meet certain requirements or try a series of non-drug therapies before they will cover the drug, or perhaps you exceeded the maximum number of covered refills. Sometimes the issue boils down to a simple mistake, such as the prescription being called into the wrong pharmacy.

Talk to your doctor or call the insurance company directly if necessary. If you rule out errors and find that your insurance company really won’t cover, your doctor may be able to get you samples or prescribe an alternate medication. You may also be able to appeal the decision and get the drug you need based on the compelling nature of your medical situation.

Look for upcoding on your bill. Doctors rely on a language known as Current Procedural Terminology (CPT) to bill insurance companies. A doctor relays your diagnosis and treatment to the insurance provider by selecting a corresponding CPT code (which is a series of numbers). For example, a new patient office visit can be billed within the range of 99201 to 99205, with 99201 representing a visit focusing on a particular problem and 99205 representing a more comprehensive visit.

Some of these codes are clear-cut, but others leave more room for the physician’s discretion. Some healthcare providers and hospital personnel have been found to “upcode,” meaning code for more expensive services than they actually offered, in order to get a bigger reimbursement. Examples would be:

• Billing a follow-up visit as if it were a comprehensive new-patient visit
• Reporting that a skin lesion that was medically excised was bigger than it actually was

Sometimes upcoding is unintentional—keep in mind that there are over 10,000 CPT codes so it’s a lot to keep straight. In other instances, doctors and hospitals have been found to intentionally upcode in order to maximize profits.

The immediate effect of upcoding is that it costs your insurance company more money, but these costs are inevitably passed on to the insured over time.

Tip: Ask your provider for an itemized bill that includes line-item details with corresponding CPT codes. These codes are available online so you can double-check the charges. If something is amiss, talk to the billing department at your doctor’s office and the claims department at your health insurance company.

If you’re typically one to sit back and let the doctor handle everything, now’s the time to become a more active participant in your healthcare. It’s better for your budget and your health to ask questions about medical recommendations and charges and become your own advocate if you see something that doesn’t add up.