Making sense of medical billing

[frugalnacho]

My insurance charges a $45 copay for a specialist visit if you have a referral. I got a referral, and visited an ENT, and paid my $45 copay.  While I was there I explained the problem I was coming in for, she took a little scope thing and shoved it up my nose, and said "yep, no wonder.  It's exactly where you described, you have a sinus infection" and gave me an rx and sent me on my way.  Now I am receiving a bill that details the $45 copay, and also has a separate $350 charge for DIAGNOSTIC LARYNGOSCOPY (reduced to $124.59 - all my responsibility).  Am I crazy for thinking this all should be covered under my $45 copay?  This wasn't a separate visit, or a separate scheduled procedure, it was literally done in less than 2 minutes while I was in the office and was directly related the reason I made the visit.  How do I go about disputing this? Or am I just stuck paying this?  And how do I prevent something like this in the future? She also looked in my ears, and my nose, and my throat, and asked me questions.  Should I stop her at every step and ask if this is included in the office visit or will be a separate diagnostic charge?

I have the money and can pay it, but it's more the principal of the matter.  I always feel like insurance and doctors offices are trying to sneak unexpected things in.

[JSMustachian]

I had the same experience going to an emergency care clinic last year to test for the flu. I paid my $25 copay, received the test which was negative and went home. Several months later I received more bills for each test they ran. I never had to pay for tests like that in the past, just the copay. Since I was never informed of the extra costs I threw them in the garbage.

[SimpleCycle]

I would call the ENTs office and ask what CPT codes were billed for the visit and ask them to review the appropriateness of that coding.

The office visit is billed as something like 99213 or 99214.  It covers an office visit of a certain length and complexity.  Usually this is what is covered by your copay.

The diagnostic procedure using an endoscope was likely billed as a separate CPT code.  It sounds like they billed 31575 based on the description, which does not sound entirely accurate as they did not examine your larynx, just your sinuses.  There are two other "scope of the nose" codes, 92511 and 31231, both of which are less expensive than 31575.

Is insurance not paying because it falls under your deductible?  Or because it was not medically appropriate?

[frugalnacho]

It was billed as 31575.  I said I was having irritation above the roof of my mouth, like I had mucus just above the back of my throat.  She grabbed a scope, went up my left nostril, kept it there about 10 seconds, pulled it out and said "yep, looks like a lot of mucus and an infection right where you said".  There was more to the appointment than that, but that was the gist of that procedure. 

I have no idea why insurance isn't paying.  I have not met my deductible, but I didn't think that mattered since my insurance just lists a $45 copay for a specialist visit.  I made an appointment with an ENT because of a sinus infection, and I guess I assumed the entire visit would be covered under my copay.  I know additional outside procedures like an xray, or lab work are additional fees, but I didn't think the dr doing a procedure for the exact thing I made the appointment for, during the appointment for that thing, would have been a separate charge.

[Abe]

Call the doctor's office and say you weren't told that procedure would be a separate charge and insurance isn't covering it. Sometimes they can convince insurance to cover it by documenting why it was necessary to diagnose, or will drop/decrease the charge. My clinic always has someone call the insurance company to confirm they'll cover a procedure for this exact reason. It's a lot easier to do it ahead of time, but they should be able to negotiate something. It's dumb, I know, sorry.

[zygote]

I occasionally see an ENT who specializes in singers, and she does a laryngoscopy to check on my vocal cords every time I go. I've never paid anything other than the visit co-pay.

I just went to look at my most recent EOB from her office, and they definitely billed my insurance for the laryngoscopy separate from the visit. The sticker price and the negotiated price are both listed, along with a copay/coinsurance of $0.

From what you described in the OP, it sounds like your insurance allowed the charge by presenting the negotiated rate, but that your coinsurance is 100% ? That sucks. I certainly never asked about the laryngoscopy before I let her do it. Like you, I just figured it was part of the office visit because it took two seconds. Is the bill you got from the office? If you can access your EOB in your online insurance portal you may get more clarity on what's going on.

Hopefully if you call your insurance and/or the ENT's office you can get this figured out. Maybe there is a way they can code it that doesn't leave you with 100% coinsurance.

[frugalnacho]

The information I got was from my insurance listed in the "claims" section of the website.  I don't see an EOB yet, just the claim, but the claim is finalized and lists what the charges are.  I haven't received the bill from the ENT yet, but based on my past experience it's going to match the claim information.  There have already been a number of billing errors from other unrelated visits, so I'm trying to be as proactive about it as I can so I can know when to dispute something, and know when to suck it up and pay it.  It sucks paying medical bills, especially when they seem egregious to me, but as soon as I accept I legitimately owe it and pay it off I can let it go and stop being bothered by it.  Outstanding balances cause me stress. 

I have a follow up visit with the ENT this week.  I don't know if she's going to do the same procedure, but I'll bring up the cost/insurance issue with her at that time.  I'd greatly prefer not to have a second $170 visit for the same problem.

My coinsurance is supposed to be 30% until my deductible is met, but there are a whole host of exceptions to that with preventative and necessary care.  This doesn't seem to fall under any of that, as my responsibility is listed as 100% of the negotiated price.

[secondcor521]

I've had sinus infections frequently the past several years and have gotten to know my local ENT and their office fairly well.

At my ENT's office, they have clearly run into the problem that you've encountered, because before they ever do one of those - I think they're called nasal endoscopies - they make sure that you know that it's a separate diagnostic code and may or may not be covered well by insurance.  They have a printout that they make you read before starting the procedure.

I've had two different insurance plans over the relevant time period; one paid 100% for the endoscopy, and the other one went to my deductible so it was 100% out-of-pocket, and they charge about $200.

So I would say you got both an office visit (that's pretty much everything except the endoscopy) and an endoscopy.  The endoscopy is medically appropriate for evaluating a sinus infection I think.  And it sounds like they billed insurance properly and your insurance paid according to your policy.

I think the only thing you reasonably have left is to complain to the doctor's office and ask them to reduce the charge based on the argument that they didn't discuss the cost and possible coverage issues with you before the procedure.  Although you could also ask your insurance company for a reduction, I don't think they are obligated to.  I doubt my insurance company would, but I honestly haven't tried because I felt like it was my responsibility to know what charges I was racking up and the doctor warned me about the insurance situation before doing the procedure.

I do agree it's hard to know what is included in what, and that's crummy.  Your thoughts and reactions are reasonable in my view.

[frugalnacho]

I spoke to the dr's office and there is nothing they can do.  They did the procedure, it was billed correctly, and it's out of their hands and on the insurance company.  She did another scope today to check that the infection was cleared up, and said it's close enough to the original visit that she won't charge me for this visit (still paid copay, just no charge for scope procedure today).

They said I'd have to talk to my insurance, but also that it wouldn't matter because they are unlikely to budge because that's how it's supposed to be billed according to my contract with them.  I'm 100% responsible for that specific procedure until my deductible is met.

How am I ever supposed to know what is covered and what is not covered before my treatment?  I'm assuming there are 100 other procedures I could have possibly needed and not been aware of before my appointment (dr may not have even been aware until they evaluated me), and I have no idea if they are covered or not until I receive a bill.  And unfortunately by the time I get the bill the procedure has already been done. Also the people administering the procedures have no idea, it's all a mystery to them and depends on your specific insurance and your specific situation, so they can't give a straight answer without getting the billing department involved, and the billing department can't get things straight without getting the insurance involved, and sometimes even the insurance company is befuddled by what's going on and can't fully explain it. 


I also got sent to have a brain MRI due to chronic daily headaches that occasionally turn into migraines.  My plan shows a $150 copay for imagine and lists MRI.  At the top of that table it specifies "All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. " but doesn't list that next to the copay amount (although some items do specify that the deductible does not apply).  Fair enough, the information is technically there, although seems slightly misleading as both my wife and I misread it as being a $150 copay only.

Now I have 2 separate charges coming through on my claims totaling $324.  One claim shows procedure code 70551 which is MRI.  The next claim, 8 days later, is listed as procedure code 7055126 which I can't find.  I don't know why there is a second charge with a specific doctor's name attached to it.   And I don't know if any more charges are going to be processed associated with this event.

I pay over $6k/yr in medical premiums, now I've paid another $600 OOP just for these 2 incidents, and no idea how much more I'll end up paying.  Good thing I'm mustachian and can afford it, but it's still very frustrating.

[JGS1980]

I spoke to the dr's office and there is nothing they can do.  They did the procedure, it was billed correctly, and it's out of their hands and on the insurance company.  She did another scope today to check that the infection was cleared up, and said it's close enough to the original visit that she won't charge me for this visit (still paid copay, just no charge for scope procedure today).

They said I'd have to talk to my insurance, but also that it wouldn't matter because they are unlikely to budge because that's how it's supposed to be billed according to my contract with them.  I'm 100% responsible for that specific procedure until my deductible is met.

How am I ever supposed to know what is covered and what is not covered before my treatment?  I'm assuming there are 100 other procedures I could have possibly needed and not been aware of before my appointment (dr may not have even been aware until they evaluated me), and I have no idea if they are covered or not until I receive a bill.  And unfortunately by the time I get the bill the procedure has already been done. Also the people administering the procedures have no idea, it's all a mystery to them and depends on your specific insurance and your specific situation, so they can't give a straight answer without getting the billing department involved, and the billing department can't get things straight without getting the insurance involved, and sometimes even the insurance company is befuddled by what's going on and can't fully explain it. 


I also got sent to have a brain MRI due to chronic daily headaches that occasionally turn into migraines.  My plan shows a $150 copay for imagine and lists MRI.  At the top of that table it specifies "All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. " but doesn't list that next to the copay amount (although some items do specify that the deductible does not apply).  Fair enough, the information is technically there, although seems slightly misleading as both my wife and I misread it as being a $150 copay only.

Now I have 2 separate charges coming through on my claims totaling $324.  One claim shows procedure code 70551 which is MRI.  The next claim, 8 days later, is listed as procedure code 7055126 which I can't find.  I don't know why there is a second charge with a specific doctor's name attached to it.   And I don't know if any more charges are going to be processed associated with this event.

I pay over $6k/yr in medical premiums, now I've paid another $600 OOP just for these 2 incidents, and no idea how much more I'll end up paying.  Good thing I'm mustachian and can afford it, but it's still very frustrating.

Welcome to modern medicine! It's a bit of a shell game, really. Copays ALWAYS go up. Coinsurance ALWAYS go up. Administrator Salaries ALWAYS go up. It's the doctors themselves (ironically as they do all the work) that have had decreasing salaries and increased work hours over time.

Your mistake, as I see it, is to not have everything managed by your PCP (Family Doctor or Internal Medicine specialist). Often times they will resolve your issue with a lot less in total costs, and should only refer you to the specialists if it is a recurring issue (i.e make sure you don't have a cancerous mass in your sinuses) or of a severity that they don't feel comfortable handling.

Most OECD countries have a Primary Care: Specialist ratio of about 50:50. In the great USA, it is more like 30:70. We get the increased costs that go along with that.

[frugalnacho]

It's definitely chronic recurring issues.  I consulted my PCP first, and got a referral only after they can't diagnose and treat the issue.  This is definitely not a case of "oh something is wrong with my sinuses, lets see a specialist" and more of a "I've already consulted my PCP multiple times, and they have referred me to a specialist". 

I don't want to get into my entire medical history, but just saying I had a sinus infection and went directly to a specialist is gross oversimplification. 

[DizzyDaisies]

I also got sent to have a brain MRI due to chronic daily headaches that occasionally turn into migraines.  My plan shows a $150 copay for imagine and lists MRI.  At the top of that table it specifies "All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. " but doesn't list that next to the copay amount (although some items do specify that the deductible does not apply).  Fair enough, the information is technically there, although seems slightly misleading as both my wife and I misread it as being a $150 copay only.

Now I have 2 separate charges coming through on my claims totaling $324.  One claim shows procedure code 70551 which is MRI.  The next claim, 8 days later, is listed as procedure code 7055126 which I can't find.  I don't know why there is a second charge with a specific doctor's name attached to it.   And I don't know if any more charges are going to be processed associated with this event.

I pay over $6k/yr in medical premiums, now I've paid another $600 OOP just for these 2 incidents, and no idea how much more I'll end up paying.  Good thing I'm mustachian and can afford it, but it's still very frustrating.

The 70551-26 is for the professional component of the MRI (the -26 is a modifier which means professional component). For imaging procedures, there are usually two charges - one for the facility and one for the radiologist who is interpreting the images and dictating the report.

[Steeze]

Sounds to me like your specialist visit is copay before deductible and anything else is coinsurance AFTER deductible, which you haven’t met yet.

Once you have accrued enough costs toward your deductible your insurance will start to kick in and pay a portion of the cost (usually 70-80%). You will still pay your part of the coinsurance up to your out of pocket max for the year.

More expensive platinum plans have no deductible and no coinsurance.

Good news is you are paying the lower negotiated costs that your insurance company agreed to pay when the doctor signed up to be in their network. If you went in with no insurance they would just bill you the full amount.

Edit: medical billing is stupid and confusing. DW and I recently went to the hospital three times in a week. We were billed by three different entities, similar procedures at each, with wildly different costs.

You would think if you went to the same building, get the same procedure, they would send you 1 bill with the same costs for each time. Nope. 3 separate bills, all different doctors, all different medical groups within the same hospital building.

It’s dumb. I budget for our OOP Max each year for this reason, and then just hope we don’t use it. So far we have never used it (all).

[PMG]

I'm just commenting so that I can find this thread and valuable conversation later.  We've been young and healthy and suddenly this year have many medical things happening.  We're reasonably smart and well educated people and it is so much work to understand and navigate. Such a waste of resources. I feel your pain Frugalnacho.

[frugalnacho]

I've only ever budgeted for max OOP when we were pregnant.  Fortunately that ended up being damn near free.  I will likely pay more for my headaches/sinus infection than I did for the entirety of our pregnancy and birth. 

Despite being frustrating to deal with these surprise charges are unlikely to have a significant overall effect on our finances or my FIRE date, and we easily have enough saved up, and enough cash flow, to just pay them off as they come in.  And as I come to understand the scope of the bills, and mentally (and financially) account for them, I am able to leave them behind me in my folder of paid off medical bills, along with the associated stress.  Then I will have freed up some capacity to stress about something else. 

[ForeignServiceWife]

Just replying to commiserate. It sounds like you got the issue figured out and that you have to pay it, which sucks. But at least you have the cash flow to cover it.

I worked for my dad for several years (he’s an allied health professional) doing insurance and billing stuff, helping people figure out their coverage and whatnot. Even with all of that experience, health insurance is confusing AF. We are VERY fortunate to have excellent health insurance through Husband’s job as a federal employee. We pay $5,000 per year in premiums ( pre-tax) for our family of five, for a no deductible plan with an out of pocket maximum of $11,000 and  extensive coverage and reasonable copays. Our plan heavily incentivizes preventive care as well. We’ve had three babies on our insurance plan. Total cost for the entire pregnancy and delivery was $175 each kid, for our portion of the hospital stay. All prenatal care including genetic testing, high risk ultrasounds, various complications, etc was all covered at no charge. All the kids’ routine checkups and immunizations are fully covered. Dental cleanings are covered for a $30 copay twice per year. We’ve had a few outpatient surgeries on the plan and the average cost for those was around $300 each. We also utilize a health savings account - we can divert up to $2500 per year pre-tax into it and it partners with our insurance and automatically transfers the money back into our bank account for out of pocket costs. My husband and I can also each  do an online survey and “health goals” to earn up to $140 each on a debit card that can be used for any health expenses from copays to massages. We go through all the HSA and rewards money each year because three children.

I describe all this to say that we pay $7,500+ annually in order to keep 5 very healthy individuals in continued good health. If it really hit the fan and one of us was seriously ill or injured, we’d have to pay our full out of pocket max and there are still things that aren’t covered under that maximum, such as prescription drugs. In reality, what we consider to be very good health insurance is really just an extremely basic level of coverage. Healthcare in the US is severely broken.

My best advice to anyone with health insurance is to find the full 150+ page pdf of your insurance coverage and bookmark it on your browser or phone. Anytime you go to any doctor, double check what’s covered and what’s not.

[DaMa]

I saw a new PCP in July.  He billed the first visit as annual physical and everything was covered.  (Except $3 charge for the blood draw to do the routine labs. WTF?)  That bill shows the annual wellness visit and a bunch of medical care codes that are screenings, etc., that are preventive and covered.

He wanted a follow up at one month due to treatment of skin issue.  Today, I'm matching my EOBs to provider bills.  He billed an office visit, and several more medical care codes.  I have never had any of these medical care codes billed with office visit before, only with annual physical.

1.) Nutritional counseling.  I assume this is him telling me to eat less fat as my cholesterol was just over the high mark.  Cost to me $48.  (I wouldn't pay that for actual nutritional counseling.)

2.) Depression screening.  No recollection of that, and it was denied because it was in the first visit. 

3.) Medication reconciliation $35.  I take 2 prescriptions.  He was updating his system which had info from a specialist visit I had 8 years ago.  It was basically me saying, "I don't take that anymore."

I'll be seeing him again at the end of this month.  I'm not sure how to explain to him that he can't bill me for things I don't expect.  That's a lot of extra $.

I pay $6000 in annual premiums and have a $2000 deductible PPO.

[Steeze]

I once called around looking for a doctor that would provide me with a list of billing codes and costs for each code prior to making an appointment. Every office I called acted like it was a ridiculous question that couldn’t be answered before services or insurance info is provided.

In a perfect world they would tell you every code and every cost upfront so you could shop around for the best prices. Then when you set an appointment you would agree to a certain set of services and costs. If something comes up during an appointment that would be additional then you are asked prior to them providing that service.

Some day the opaqueness of the medical billing system in the US will be illegal. I am sure we could drive down healthcare and insurance costs significantly just by making the billing transparent.

It is insane to me that you go to the hospital for a surgery and receive bills from half a dozen different entities. You schedule with your doctor and your hospital which is in network and then somehow are getting billed by doctors you never met that are out of network.

Then once you make the payments online you keep receiving paper bills for months. Never sure if you paid this one since you received them all piece meal and some include outstanding balances which you already paid. So you have to call every time to see if you actually owe the amount on the bill they mailed you.

The whole thing stinks. At best disorganized, convoluted, and confusing. At worst racketeering and fraud. Unfortunately we the public cannot tell the difference.

That is the state of affairs in the US though. Just keep paying those premiums no matter how much they increase... another 30% this year? Sure! Raising my $6000 deductible to $8000? Might as well.

[frugalnacho]

I once called around looking for a doctor that would provide me with a list of billing codes and costs for each code prior to making an appointment. Every office I called acted like it was a ridiculous question that couldn’t be answered before services or insurance info is provided.

In a perfect world they would tell you every code and every cost upfront so you could shop around for the best prices. Then when you set an appointment you would agree to a certain set of services and costs. If something comes up during an appointment that would be additional then you are asked prior to them providing that service.

Some day the opaqueness of the medical billing system in the US will be illegal. I am sure we could drive down healthcare and insurance costs significantly just by making the billing transparent.

It is insane to me that you go to the hospital for a surgery and receive bills from half a dozen different entities. You schedule with your doctor and your hospital which is in network and then somehow are getting billed by doctors you never met that are out of network.

Then once you make the payments online you keep receiving paper bills for months. Never sure if you paid this one since you received them all piece meal and some include outstanding balances which you already paid. So you have to call every time to see if you actually owe the amount on the bill they mailed you.

The whole thing stinks. At best disorganized, convoluted, and confusing. At worst racketeering and fraud. Unfortunately we the public cannot tell the difference.

That is the state of affairs in the US though. Just keep paying those premiums no matter how much they increase... another 30% this year? Sure! Raising my $6000 deductible to $8000? Might as well.

And even if you call to check the balance, because there are so many parties involved they can't give you a straight answer.  So the hospital may say you have a balance of $0, but you may receive charges from a number of other doctors that were there and you aren't even aware that they are going to bill you eventually.  There is no single entity to square up your bill, so I feel like it's alway potentially hanging over our head.  Maybe a rogue bill from a year ago will suddenly show up in my mailbox.  It's happened numerous times before.  I feel like doctor's office billing is more straightforward because there aren't those other parties that will give me a surprise bill, instead it's all likely to come directly from the office. It's still a total mess though and they usually can't provide accurate billing estimations ahead of time. 

I had a similarly frustrating experience at the dentist one time.  My wife needed work done on a couple teeth, I don't remember exactly what the work was.  Ok billing department, how much is it going to cost?  We don't know.  What do you mean you don't know? You know our insurance information, you know the codes for the procedures that YOU are going to bill, and you know how much our deductible is and how much we've paid...so how much is it going to cost? We don't know; we can't know until we do the work and actually bill it.  Ok, so submit the codes and get an estimate.  We can't, we can't submit it until the work is done.  WTF how is this an unknown?! You are the ones billing, and you have codes.  This is the most deterministic system possible.  You put in specific codes, and insurance pays a specific amount, and some specific portion of the balance is my responsibility.  You have agreements with the insurance company that sets the prices for the remainder of my plan year.  It's completely deterministic, and there is only one possible cost that can result from this situation, so just tell me what that cost is, because I don't believe you when you say you can't determine it ahead of time, you absolutely can, and it will be the exact same whether you had already done the work, you do the work today, or you do the work in 2 weeks.  "We don't know".  THEN CALL THE FUCKING INSURANCE COMPANY AND GIVE THEM THESE CODES AND GET A PRICE! Tell them to plug these exact codes into their system and see what price it spits out so we can know, because immediately after this work is done they are going to do *EXACTLY* that and send us a real bill.  If they can determine a price from their 100% deterministic system and send us a bill, they should be able to do it right now.  "We can't, we don't know".  We ended up just getting the work done without ever receiving an estimate, because what are we gonna do? Not get necessary dental work done because they can't provide an accurate estimate?  Boy was that frustrating though.

[DaMa]

I have EOBs mailed to me, because the insurance companies will replace them online when they make changes and you can't see the original.  Right now I have one paper EOB for 5 xrays I had done in July, and the online version is NOT there at all.  While I was on the phone asking questions about two other issues, I mentioned the missing EOB.  The CSR checked and told me the claim was resubmitted and under review.  I've already gotten a bill from the provider that matches the EOB I have.

Can't wait to see what changes.

BTW, 1 PCP visit (+annual), 1 specialist visit, 5 xrays, various labs, and a couple of cheap prescriptions, and I'm at $1400 out of pocket already this year.  Thankfully there was nothing found during my colonoscopy so it remained preventive -- no out-of-pocket.

And did I mention I got billed $102 for the COVID screening I had to have before the colonoscopy.  Apparently the provider didn't bill it with the appropriate codes for it to be covered.

I could tell these stories all day.  It took me over a year to get my son's family's billing fixed, and we gave up on a couple of items.