Incorrect medical bill, clinic won't budge. Pay, fight it, or ignore?

[FireLane]

Back in February, my wife @Mrs. FireLane got her first colonoscopy. Her brother died of colon cancer this year, so medical guidelines say she's at elevated risk due to family history, but it was 100% preventive. She wasn't experiencing any symptoms or other problems that might have led her to believe she had a specific reason for needing it.

It was routine and had no complications. They removed three polyps, but they proved not to be cancerous.

Under the ACA, private insurers have to fully cover colonoscopies and other preventive care with no out-of-pocket costs. However, a few weeks later, she got a bill in the mail. It transpires that the clinic that did the procedure billed it as "diagnostic" - which, of course, isn't fully covered by insurance and is more expensive.

Their reasoning is that if there'd been no polyps, it would be preventive, but because some were found, it was diagnostic. That strikes me as dishonest at best, fraudulent at worst. The distinction of preventive vs. diagnostic, I would think, turns on the reason the test is performed in the first place. It can't be changed retroactively based on the outcome.

We've gone through, no exaggeration, five rounds of the following: Mrs. FL gets a bill in the mail; she calls the clinic's billing department to insist that this was preventive care and they need to code it as such; the person on the phone says they understand the issue and agrees to review and reevaluate the bill; and a few weeks later, she gets another bill.

I found an article on NPR about this exact shady practice. It seems to be widespread:
https://www.npr.org/sections/health-shots/2022/05/31/1101861735/colonoscopy-cost-cancer-screening

The Centers for Medicare & Medicaid Services has also issued an opinion stating that medical providers aren't allowed to do this:
https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf

She just went through another iteration of this, and we got yet another bill in the mail for $500. We could afford to pay it, but this seems like a matter of principle to both of us. The clinic is skirting, if not flouting, the law by billing incorrectly so that they can charge more.

Mrs. FL has called her insurance company, but they haven't helped. They say the clinic would have to bill them using the right code. Unfortunately for us, they have no incentive to help, because we haven't hit our out-of-pocket maximum. If the bill were coded correctly, they'd have to pay it. As it is, we'd have to cover it ourselves.

What would you do in this situation? Bite the bullet and pay so they stop hassling us? Go through another round of phone hell with another minimum-wage call-center employee who has no power to do anything, and end up in the same situation a few weeks down the line?

Or - and this is the option I'm seriously contemplating - we could write the clinic a letter explaining the situation one more time, making it clear that this bill is incorrect and we're not going to pay it, and if they want their money, they have to bill Mrs. FL's insurer with the correct code.

Medical bills under $500 no longer appear on credit reports, and this is right around that threshold, so I'm guessing we could ignore it without consequence. I'm betting they're not going to sue over this, both because it wouldn't be worth their while for such a small amount, and also because I'd wager they don't want to defend this sleazy practice in court.

Am I being too reckless?

[Dicey]

I would fight it tooth and nail. Print out that article and deliver it them in person. A copy of her brother's death certificate might light a fire under them, too. Last resort is to threaten the going to the media, but that only works if you're willing to follow through. There is the equivalent of "7 on Your Side" in every market. They're always looking for material, and the sadness of this situation makes it likely they'll help. Sorry for your tamily's loss.

One does these things because they can. If it helps someone else out, that's a deposit to the ol' karma bank.

[Freedomin5]

I would pay it and be thankful it wasn’t cancer. Extra testing and work had to be done because of the polyps, and they should be compensated for it.

It’s like someone went to the dentist for a routine teeth cleaning -> preventative care. They were told it was covered by insurance.

While getting their teeth cleaned, the dentist discovered a cavity. The dentist then had to do extra work to fill the cavity. Cavity filling is not fully covered by this person’s insurance.

According to the dentist, cavity filling is no longer a routine teeth cleaning, and the dentist would be correct. The dentist would not have known whether a cavity filling was needed until they looked inside the person’s mouth. So before looking at the person’s mouth, they would have quoted the billing for a routine teeth cleaning, because that’s what the person said they wanted. It wouldn’t be until after looking at the person’s mouth and finding out there’s more going on than what they were told that the dentist would have to adjust the procedure to address the real issue.

My mom had a colonoscopy last year, and they were clear before they started the procedure that if polyps were found, they would tack on the surgery to remove the polyps and test for cancer. The colonoscopy was routine and preventative. The polyps removal and testing was considered diagnostic because the purpose of the removal and testing was to diagnose possible cancer.

I would only fight it if they consent your wife signed clearly stated that the preventative fee includes polyps removal and testing and that the clinic considered all three procedures - colonoscopy, removal, and testing to be preventative, not diagnostic.

[FireLane]

I would pay it and be thankful it wasn’t cancer. Extra testing and work had to be done because of the polyps, and they should be compensated for it.

I understand that people should be compensated for their work, but the way the clinic should get their money is by billing our insurance. Everything done as part of the colonoscopy, including polyp removal and testing, is part of preventive care and should be covered at no out-of-pocket cost. That's not my opinion, that's what the law says.

I linked to the Centers for Medicare & Medicaid Services regulation about this. I'll quote the relevant part:

The Departments have issued several FAQs clarifying that if a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, cost sharing may not be imposed for items and services that are an integral part of performing the colonoscopy. These items and services include:

• Required specialist consultation prior to the screening procedure;
• Bowel preparation medications prescribed for the screening procedure;
• Anesthesia services performed in connection with a preventive colonoscopy;
• Polyp removal performed during the screening procedure; and
• Any pathology exam on a polyp biopsy performed as part of the screening procedure.

The reason I consider this a matter of principle is because the government mandated that colonoscopies and other preventive care be fully covered, specifically to remove a common obstacle for getting them. What this clinic is doing runs directly against the intent of that law.

This bill isn't a big deal for us, but for some people, it would be. If everyone who got a colonoscopy knew going in that they'd either be charged nothing, or hundreds or thousands of dollars, based on a roll of the dice - then more people would skip their colonoscopies out of fear of a bill they couldn't afford, and more people would die needlessly of cancer that could've been cured if it had been caught earlier.

[Freedomin5]

Well, in this case, it seems like the law is clearly on your side. I change what I said before. Send them the information from the regulation, send them links to the relevant parts of the law, and then fight it.

Can you file a complaint against them as well? Is there something like the Better Business Bureau for medical clinics? Or their licensing body? I assume medical clinics in the US are governed by a licensing body.

(Sorry, not American - don’t know much about how medical clinics are run in the US)

[swashbucklinstache]

How old is your wife?

...performed as a screening procedure pursuant to the USPSTF recommendation...

Patient Population Under Consideration
This recommendation applies to asymptomatic adults 45 years or older who are at average risk of colorectal cancer (ie, no prior diagnosis of colorectal cancer, adenomatous polyps, or inflammatory bowel disease; no personal diagnosis or family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer [such as Lynch syndrome or familial adenomatous polyposis]).

The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years.

The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years.

Adults aged 76 to 85 years   The USPSTF recommends that clinicians selectively offer screening for colorectal cancer in adults aged 76 to 85 years.

If she's under 45 she should get screened, but while that's true and while a doctor may have recommended she get screened, I don't see anything in the USPSTF recommendation saying that it is recommended to her. We need to be careful that preventative = free isn't always exactly correct. I'm definitely not a lawyer though, just another layman's read.

I would send a polite but stern letter, on the odds that this is just regular mixup. If that doesn't work I see a few options.

• Pay up in full
• Call the clinic and offer to pay 50% or similar
• Go talk to a lawyer. They might tell you you're wrong or that you're right but it will cost less to just pay. Or maybe you've got a case or a letter from them will do the trick.
• Let it go to collections which likely has basically no impact on your life

[FireLane]

How old is your wife?

She's under 45, but that recommendation is for people at average risk. She's considered higher risk because she had an immediate family member who was diagnosed with colon cancer at an early age.

Anyway, I think this would matter if her insurance company was refusing to cover the procedure, but that's not the problem. Her doctor recommended she get screened, and the insurance company agreed and precleared it. The problem is the clinic isn't sending it with the right billing code for them to pay up.

I do agree with the letter recommendation. I'm working on writing one that tells them to straighten their shit out in the nicest legal manner.

[Dollar Slice]

Keep arguing with them. I had something similar that cost only about $100. Very similar issue - someone miscoded something somewhere and the insurance company therefore insisted that an urgent care clinic was a primary care doctor and therefore it wasn't covered (because they weren't my PCP and I couldn't just go there with no referral and yadda yadda). I patiently explained that primary care doctors don't operate out of the back of a CVS at 5PM on a Sunday under the title "minute clinic." They say gosh, yes, of course, how silly, we'll fix it. They send me another bill two weeks later. Round and round it went for 9 months. They paid it eventually, because they were clearly wrong, and they were just hoping I would cave and pay.

Insurance companies do this ON PURPOSE. They refuse to pay a certain percentage of legit claims ON PURPOSE. They drag it out forever and hope that you'll decide it's not worth the time. This is just part of the way they make profits. It's abhorrent. They've done it to me more than once. They denied my foot surgery, they denied my physical therapy, they denied my mom's knee surgery, they denied my antibiotics, they denied my migraine meds. The sicker you are the more you see it as a pattern. You have to just insist and put your foot down and make them cover what your premium is supposed to get you coverage for.

[GilesMM]

How old is your wife?

She's under 45, but that recommendation is for people at average risk. She's considered higher risk because she had an immediate family member who was diagnosed with colon cancer at an early age.

Anyway, I think this would matter if her insurance company was refusing to cover the procedure, but that's not the problem. Her doctor recommended she get screened, and the insurance company agreed and precleared it. The problem is the clinic isn't sending it with the right billing code for them to pay up.

I do agree with the letter recommendation. I'm working on writing one that tells them to straighten their shit out in the nicest legal manner.

The age is the issue.  The clinic is going to code it as diagnostic at that age, regardless of what happened to another family member.  You will have to somehow convince them otherwise. Does the law say something about this situation?


I had a polyp and the doctor recommended a follow-up in three years. Three years later I set it up and they pre-coded it as diagnostic so I canceled. I told them I would do it when they coded it right.  They never did but another clinic did during year four (or maybe five).

[swashbucklinstache]

Keep arguing with them. I had something similar that cost only about $100. Very similar issue - someone miscoded something somewhere and the insurance company therefore insisted that an urgent care clinic was a primary care doctor and therefore it wasn't covered (because they weren't my PCP and I couldn't just go there with no referral and yadda yadda). I patiently explained that primary care doctors don't operate out of the back of a CVS at 5PM on a Sunday under the title "minute clinic." They say gosh, yes, of course, how silly, we'll fix it. They send me another bill two weeks later. Round and round it went for 9 months. They paid it eventually, because they were clearly wrong, and they were just hoping I would cave and pay.

Insurance companies do this ON PURPOSE. They refuse to pay a certain percentage of legit claims ON PURPOSE. They drag it out forever and hope that you'll decide it's not worth the time. This is just part of the way they make profits. It's abhorrent. They've done it to me more than once. They denied my foot surgery, they denied my physical therapy, they denied my mom's knee surgery, they denied my antibiotics, they denied my migraine meds. The sicker you are the more you see it as a pattern. You have to just insist and put your foot down and make them cover what your premium is supposed to get you coverage for.

It is true that insurance companies sometimes reject as a first step way more than they should. I think most of the time it's not such malice though, just bad process or incompetence. In this case it's the clinic.

Just for laughs, my version of this was actually funny in the end. In my case it was, rather ironically, the person responsible for providing newly mandated up front estimates. They didn't have enough clinical knowledge and accidentally selected an extremely specialized version of my procedure in the system. Once that had been selected there was no way to change it apparently, up through insurance being billed. Luckily for me the insurance company forced to hospital to change it because they weren't going to pay 10k for an MRI, 7k for this, 8k for that when the actual cost is 3k or so usually.

[swashbucklinstache]

How old is your wife?

She's under 45, but that recommendation is for people at average risk. She's considered higher risk because she had an immediate family member who was diagnosed with colon cancer at an early age.

Anyway, I think this would matter if her insurance company was refusing to cover the procedure, but that's not the problem. Her doctor recommended she get screened, and the insurance company agreed and precleared it. The problem is the clinic isn't sending it with the right billing code for them to pay up.

I do agree with the letter recommendation. I'm working on writing one that tells them to straighten their shit out in the nicest legal manner.

I agree in principle and spirit of the thing. I do worry it's enough of a gray area, since I don't see any official USPSTF recommendation for people under 45 and, to my layperson read, all they're required to do is follow USPSTF. Gray area = time to call a lawyer in the field, if the other options don't work or don't suit you. That said, realistically since the procedure is done already and you're a mustachian they have no real recourse that can affect you. I think, faced with an option of getting some money from insurance or no money from you, they'll wrap all this up and go with the former.

[Dollar Slice]

It is true that insurance companies sometimes reject as a first step way more than they should. I think most of the time it's not such malice though, just bad process or incompetence. In this case it's the clinic.

I think you would be disappointed to find out what really goes on. ProPublica has done some eye-opening deep-dive reporting on the health insurance industry in the last couple of years... e.g. https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims

Dopke, the doctor who turned down van Terheyden, rejected 121,000 claims in the first two months of 2022, according to the scorecard. (this is ~6 denials per minute - Dollar Slice)

Dr. Richard Capek, another Cigna medical director, handled more than 80,000 instant denials in the same time span, the spreadsheet showed.

Dr. Paul Rossi has been a medical director at Cigna for over 30 years. Early last year, the physician denied more than 63,000 PXDX claims in two months.

Rossi, Dopke and Capek did not respond to attempts to contact them.

Howrigon, the former Cigna executive, said that although he was not involved in developing PXDX, he can understand the economics behind it.

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees.

[swashbucklinstache]

It is true that insurance companies sometimes reject as a first step way more than they should. I think most of the time it's not such malice though, just bad process or incompetence. In this case it's the clinic.

I think you would be disappointed to find out what really goes on. ProPublica has done some eye-opening deep-dive reporting on the health insurance industry in the last couple of years... e.g. https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims

Dopke, the doctor who turned down van Terheyden, rejected 121,000 claims in the first two months of 2022, according to the scorecard. (this is ~6 denials per minute - Dollar Slice)

Dr. Richard Capek, another Cigna medical director, handled more than 80,000 instant denials in the same time span, the spreadsheet showed.

Dr. Paul Rossi has been a medical director at Cigna for over 30 years. Early last year, the physician denied more than 63,000 PXDX claims in two months.

Rossi, Dopke and Capek did not respond to attempts to contact them.

Howrigon, the former Cigna executive, said that although he was not involved in developing PXDX, he can understand the economics behind it.

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees.

I am extremely familiar with this industry. My comment was more an attempt to help not get this thread too focused on insurance activity since this is a clinic-side issue.

[Boll weevil]

No experience with something like this but I think letters are very easy to ignore and you would be better off with a face-to-face meeting with their billing department.

If you do visit in person, another thing I’ve heard that sometimes works is to offer a small amount to be paid that day to fully settle the bill. Basically you’re saying they can have that today or fight you for months, in which case the net will probably end up being the same. If you go that route, make sure you leave with a receipt saying the balance owed is -0-. Technically this would be going against the principle of the issue, but do you really want to fight this for months?