Medical Billing Errors: What can go wrong? What can you do? - 1 - The bill's inception

Medical Billing Errors: What can go wrong? What can you do?

Step 1: The bill's inception

Roughly two dozen people might take action in this stage of the process. It begins

when a patient and surgeon pick a hospital, usually based on where the doctor has privileges, the patient's insurance coverage and the hospital's reputation. Once a surgery date is set, hospital staff begin gathering information about the patient and insurance coverage. This stage ends about a week before the surgery when the patient undergoes medical tests in final preparation for surgery.

The referral

The first information about the patient is entered into the hospital's computer system.

• A surgeon calls the hospital to schedule surgery.

• A hospital scheduler takes information about the patient, checks for available operating room dates, and arranges the surgery based on the surgeon's instructions.

Preregistration

Hospital employees gather a patient's insurance information, inform the patient about any pre-surgery medical tests and talk to the insurance company regarding authorization.

• A hospital preregistration employee, often a nurse, talks to the patient over the phone to obtain insurance information and tell the patient about any advance medical tests, such as blood work and X-rays, that will be necessary.

• Another hospital staff person calls a representative at the patient's insurance company  to confirm coverage, collect benefit information and begin the process of getting insurance authorization for the surgery and any other tests or treatments that require approval.

• Obtaining authorization can be a lengthy discussion, involving the surgeon and one of the insurance company's doctors. Hospital personnel may copy paperwork and deliver it to the insurance company, where a clerk files it in the patient's file for review by an administrator. Sometimes lawyers for the hospital and insurance company become involved if there is a problem with authorization.

Loop: The authorization process may be repeated, either now or later, with discussions about medical necessity and an exchange of paperwork, over different aspects of the patient's care. This may become necessary if a patient's condition worsens and requires additional surgery or treatment.

Even when the insurance company approves surgery and other treatment, it includes a reminder to the hospital that "this will not guarantee payment" because, for example, there might later be a dispute over the care provided, or a patient's insurance coverage information might be inaccurate.

• Based on the insurance authorization, a hospital employee will calculate what the total charges might be, how much might be covered by insurance and how much the patient may pay out-of-pocket. This is the starting point for a discussion about possible financial assistance -- loans, payment plans and charity care.

Pre-admission tests

Typically, a patient goes to the hospital or a doctor's office about a week before surgery for a checkup and pre-admission tests.

• A registration person checks in the patient, confirming personal and insurance information.

• Nurses and other clinical staff check vital signs, draw blood and take X-rays, as ordered by the surgeon.

• Behind the scenes, a technician processes lab tests, a radiologist reads the X-rays, a pathologist assures the accuracy of lab tests, and the surgeon confers with the radiologist.

• A hospital's financial counselor will meet with a patient who has a high-deductible insurance plan or no insurance coverage. The counselor will discuss what the hospital expects the bill to be, based on its model of others who have had the surgery, and what the cost might be to the patient.

What can go wrong?

Throughout the medical record's journey, each person involved in giving care and many who provide support can make a simple mistake that affects the bill. During this initial stage, the surgeon or the surgery scheduler could misspell the patient's name or make another clerical mistake. Such errors are usually caught, but they can create problems later.

During pre-admission testing, every action is entered into the patient's medical record and presents additional opportunities for mistakes. Entry errors create confusion, and tests that are improperly done -- for instance, X-rays that must be reordered -- drive up the bill.

Getting insurance company authorization for treatment is a common area of costly mistakes and disputes. In part, this is because the hospital must accurately understand all of the requirements of the patient's insurance company. And the insurance company must have full documentation that the treatment is medically necessary.

Paperwork, and even electronic files, sometimes get lost. And both sides must be error-free in entering dates and seemingly less-significant pieces of information. Even a small mistake can void an authorization.

What can you do?

While the patient may not be involved in the scheduling or has little ability to determine what tests are necessary, he or she can make sure personal and insurance information is correct. At the beginning of every appointment, ask a staff member to read back basic registration information. Talk with the medical team to ensure that you understand what care is being given and why.Listen and correct any information that's inaccurate. Also, contact your insurance company before any procedures or tests to make sure you understand if you're covered and what's required to obtain payment.

Remember that radiologists and anesthesiologists usually bill for their services separately unless they are employed by the hospital. Make sure these providers are part of your insurance network. Using an out-of-network doctor can result in significantly higher bills.