If you process medical claims of any kind for payment, you already know the process is fraught with potential for errors and over charges. The challenge is that when your focus is on processing and payment, there’s less room for the necessary reviews and audits to catch and correct these errors. The downstream impact of this is often increased costs to your already overburdened plan and significant economic impacts for the patients, your members.
We’re not here to point fingers. Any process with humans is going to involve human error to some degree. However, we think there is a better way. In addition to automated reviews and audits, highly skilled medical claims specialists who understand medical and insurance terminology, and medical insurance coding can make an enormous difference when it comes to resolving medical billing errors and issues. And when these specialists are also experts in customer care, they can also take a lot of the fear and anxiety out of resolving those issues for the impacted patients.
According to Medical Billing Advocates of America 80% of medical bills contain errors1. If we focus specifically on reviews of in-network claims for billing errors in coding and appropriateness in charges based on the patient case, you can recover a tremendous amount of money for your health plan. In-network refers to providers, specialists or health care facilities that are part of a health plan’s network of contracted providers. Routinely billing errors are seen on a claim when a provider’s or facility’s billing department lists excessive quantities or lists separate codes that should have been included in the primary procedure or special care area charge. We’ll explore this in more detail below.
One of our clients recently submitted a large, in-network, inpatient hospital claim for our review. This claim not only had numerous billing errors, but our expert clinical unit found charges unbundled from general anesthesia and special care area charges. Unbundling is where the biller separately codes for items or procedures that are inherent to the primary procedure2. The inpatient hospital claim involved a total knee replacement. In one example of excessive billing, the facility listed general anesthesia charges and then separately listed the anesthesia medications. These anesthesia medications are routinely only administered by an anesthesiologist and only administered during surgery or in recovery and that was not the case for this service. These separately billed anesthesia medications are charges that should never have been on the bill.
| Anesthesia Charges | ||||||
| Rev Code | Line Description | Qty | Total Billed | Inappropriate Billing | Recommended Allowable | |
| 370 | ANES SRVS GENERAL 1ST 30MIN | 1 | $1,283.75 | $0.00 | $1,283.75 | |
| 370 | ANES SVCS GENERAL ADD 15 MINS | 9 | $2,817.00 | $0.00 | $2,817.00 | |
| 250 | FENTANYL 100MCG/2ML VL | 1 | $11.50 | $11.50 | $0.00 | |
| 250 | EPHEDRINE 50MG/1ML VL | 1 | $96.00 | $96.00 | $0.00 | |
| 250 | J1885 | KETOROLAC TROM 15MG INJ (30MG) | 2 | $8.00 | $8.00 | $0.00 |
| 250 | J0131 | APAP 10MG INJ (1000MG/100ML) | 300 | $675.00 | $675.00 | $0.00 |
| 250 | J2250 | MIDAZOLAM 1MG VL (2MG/2ML) | 2 | $4.50 | $4.50 | $0.00 |
| 250 | J2405 | ONDANSETRON 1MG/0.5 ML VL (4MG) | 12 | $9.00 | $9.00 | $0.00 |
| 250 | J0131 | APAP 10MG INJ (1000MG/100ML) | 100 | $225.00 | $225.00 | $0.00 |
| 252 | C9290 | BUPIVAC LIP 1MG INJ (1.3%-20ML) | 250 | $1,040.00 | $1,040.00 | $0.00 |
| 258 | J7120 | LACTATED RINGERS 1000ML IV | 2 | $100.00 | $100.00 | $0.00 |
| 270 | CABLE ECG 3/5LD 1 PC W/SNAP | 1 | $66.25 | $66.25 | $0.00 | |
| 270 | CIRCUIT BREATH SNGL LIMB | 1 | $31.50 | $31.50 | $0.00 | |
| 270 | TUBE ET NAS-OR CPO SI 5.5/7.5MM | 1 | $79.00 | $79.00 | $0.00 | |
| 270 | TRAY SPINAL PENCAN 24G 4IN | 1 | $65.25 | $65.25 | $0.00 | |
| 370 | SEVOFLURANE | 1 | $338.25 | $338.25 | $0.00 | |
| TOTALS | $6,850.00 | $2,749.25 | $4,100.75 | |||
That extra and inappropriate $2,749.25 is being paid for by the patient or the health plan and that’s a problem. Why should you or your health plan have to pay for these separately listed items in addition to the primary procedure or special care area charges, when it is normal to only pay the primary procedure?
Have you encountered excessive charges on medical bills where the patient has been balanced billed by the provider? Please, join the conversation and tell us about it.
1 https://billadvocates.com/medical-billing-errors-can-make-life-nightmare/
2 http://www.aapcps.com/news-articles/bundling-basics.aspx
