What Happens Between the Treatment Room and the Bill You Receive
Medical treatment is stressful enough without the nightmare of billing that follows. You leave the hospital/doctor’s office. You might feel relieved that the medical part is over, and then, weeks later, you get a bill. The numbers are higher than what you expected. There are all these codes you don’t understand. Sometimes there are charges for services you know for sure never happened.
Medical billing is a bit of a black box for many. Something happens between when care is delivered and when the bill is processed, and people outside the industry has no clue what it is. Learning about this process won’t make it any less maddening, but at least it clarifies why bills are often wrong and what you can do about it.
They Have to Code First
So, what happens? Well, things get translated into billing codes. It’s not as simple as someone notes "blood test" or "X-ray." It’s specific medical billing codes with numerically assigned values used within the insurance/billing apparatus.
Someone – most often a medical coder – receives your file and assigns codes based on the diagnosis they attributed to your symptoms and every procedure, supply, and level of service used. This starts to go wrong here. They might not be in the room; they’re going off notes – which often are scribbled on paper – and subjective interpretation of what codes fit best.
A doctor might have an illegible note that determines one thing vs. another from a coder’s perspective. Someone might come in and bill for two units of something when it should have been only one. It’s not always intentional or as blatant as upcoding – a method where they bill for something more expensive – but sometimes mistakes happen.
The Insurance Element
Next, the code gets sent off to insurance. Yes, now it goes to another world where other professionals use their assigned coding mechanism to determine what’s covered under your plan, what’s applicable to your deductible, and how much per code they’ve negotiated to cover/cash out.
The insurance company has a contract with your healthcare provider with set amounts per code they recommend/use for coverage. But if the code doesn’t fully match what’s in the system or notes, it’s rejected or only partially accepted, which means someone’s revenue producing wings get clipped.
Therefore, it’s sent back to the billing department, where someone must determine what’s missing from insurance. Resubmission occurs or denial that you’ll have to cover costs because insurance didn’t find certain charges helpful during their review.
At this point, it’s back-and-forth for weeks (or months). In this time, you may find bills that are adjusted, notices that vaguely point out changes that don’t make sense to anyone except those in the know – which isn’t you – and unless you plan to appeal every time, you assume insurance did its job well enough.
They’re Not So Rare
Since billing errors are not rare but quite common, this is justified. A large percentage of hospital bills have some sort of error – with duplicates for items/services you didn’t receive, incorrectly charging one quantity instead of another, wrong coding that prices it higher for the patient, etc.
Why? Because it’s ridiculously complicated. The more people who intervene within this short period post-treatment before the actual bill goes in your hands, the more likely something will get mixed up, lost in translation or not addressed properly.
And because patients have no stake in the game (i.e., if they get charged for two units instead of one and it’s never flagged because it benefits the hospital more than it does the patient), it’s your responsibility to call them out on mistakes that may not be in your favor – but absolutely benefit them.
What Actually Goes Into Your Bill
But what’s in the bill? Yes – date of service/procedure codes/reasoning for charges and dollar amounts break it all down. Some hospitals separate what insurance paid vs what you owe; others just give you a total.
What’s more frustrating is vague responses. "Pharmacy" doesn’t tell you which medication was received; "lab services" could mean 1 test or 5 tests; "supplies" is vague enough to be anything from gauze to expensive equipment that should’ve come from a doctor – and not billed to you.
Thus, you can’t corroborate your memory with what’s in black and white because it ultimately serves them better. If hospitals made this a transparent process of collaboration with detailed, itemized expectations per each maneuver, instead of running them through their systems to see what works best for revenue, they’d find people less likely to catch discrepancies.
When Not To Pay
So, what shouldn’t you pay? Anything that looks wrong – or anything that doesn’t match up with what you’ve seen/heard/offered relative to payment should raise a red flag – charges for services you know didn’t happen, duplicated line items that look identical (there shouldn’t be two $60 co-pays), amounts that seem significantly higher relative to what you’ve heard before, or bills coming from ancillary providers you never saw on your chart (an anesthesiologist who never mentioned they’d be there).
You should also flag things that are mistakenly classified under different modalities – preventive care that you’re receiving as diagnostic or generic medications getting billed at their brand-name price.
Depending on how wrong things go – and if people can help – understanding how to dispute a medical bill can save you valuable dollars. It’s not an easy process but one worth exploring if you’ve got significant charges that don’t make sense.
Reality of Disputing Your Bill
Disputing a bill takes effort; if you don’t have an itemized bill, you must get one – that means requesting a detailed version that lists every minute charge incurred since many give general charges. Then you assess what made sense vs what went wrong and apply those findings to whatever documentation you acquired (discharge papers/treatment summary).
Present errors by contacting the billing department; state what’s incorrect, but don’t expect people to help immediately. You can send multiple letters back-and-forth; keep detailed notes of whom you’ve talked to because they’re going to give you the runaround first.
But they’re going to hold all the power – they can send collections after you while you’re still disputing it, and if they’ve done little work on their end without notifying patients, it’s frustrating down the line.
What Fails This Process
What fails this whole process is that most of it happens outside of your purview. Patients should be involved with coding what they were serviced/costed and told what insurance plans would compensate – but all those choices are made without patient involvement until it’s time for payment.
There’s little accountability; if a restaurant charged you for items you didn’t order – but instead charged you four times for something expensive you’d notice immediately – you wouldn’t pay because it’s egregious. Medical expenses are so convoluted with time and detailed accounts that there’s no real time to fight back effectively.
Sure – and it’s true – medical billing is complicated because medicine itself is complicated. But other nations have simpler means of healthcare billing; it’s clear the complexity serves the needs of the hospitals and companies involved – not patients.
Where You Can Take Control
You can’t control how this system ultimately looks. However, there are ways to protect yourself in it. Always inquire about cost estimates before procedures when applicable; keep your records of paperwork from offices/hospitals; receive itemized bills from the start – instead of waiting until something looks wrong – and don’t assume that because it comes from a hospital/doctor’s office, it’s right.
There will always be a gap between what happens and where treatment occurs and where that’s charged out because far too many people are involved; too many codes make sense; too many avenues allow something legitimate against your integrity if a mistake is made.
But understanding there even is a gap – and why such mistakes aren’t abnormal but frequent – helps push back when applicable when your bill doesn’t make sense. You’re not being difficult; you’re being accurate against mistakes outside your control.