Target 8: Wrong code, not covered

Target 8

GRAND RAPIDS, Mich. (WOOD) — Ricardo Ramirez doesn’t go to the doctor often, but one visit he never passes up is his annual physical.

“We have a higher deductible and it’s (annual physical) covered 100 percent,” Ramirez explained.

Most health plans must cover a set of preventive services, like shots and screenings tests, for free, so Ramirez wasn’t out of line thinking he would be covered. But when Ramirez got his bill several months later, he was surprised to see he owed $158.

“Now they said they’d rebill it, but they haven’t and it’s been over two months,” he said.

He and his wife, Marie, track what they pay for out-of-pocket because of their high-deductible plan. That’s how they noticed the bill after his annual physical.

“Someone made the decision to not call it a physical, but to call it a follow-up. A follow-up to what? I haven’t seen the doctor in over a year,” Ramirez pointed out.

“The frustration is very high. It’s awful, actually,” Marie Ramirez said.

Ramirez sees his doctor through Bronson Healthcare. Bronson refused an on-camera interview with Target 8, but said its patient relations team has had several contacts with the Ramirezes to try to clear up any confusion with their bill.

Their corporate communications department sent this statement to Target 8:

“We understand that what is and isn’t covered by insurance varies among health plans and that bills for medical care are sometimes difficult for patients to interpret. Bronson has patient relations representatives available to help answer questions individuals may have about their care and about their bills.

“We encourage patients to discuss their coverage with their insurance company (or human resources department of their employer) before visiting their provider, to be clear on what services their health plan covers. 

“Bronson’s medical practices follow the Centers for Medicare and Medicaid Services (CMS) guidelines for coding office visits. The code determines the charge for the visit. While an appointment may be scheduled as a general physical, if other medical conditions are discovered or brought up by the patient during the visit that require further inquiry and testing beyond the scope of the physical, then the visit is coded to reflect those additional services.

“Bronson is always looking for opportunities to improve communication with patients so they know what to expect. We are now asking our office staff to confirm with patients who are scheduling physicals that the primary purpose of the visit is preventive in nature versus a visit for a medical problem beyond the scope of what insurance covers for a general physical.”

Every medical service has a code and one number can be a game changer. Insurance companies use that code to determine what it will pay for according to your plan.

“Codes have always been in place and have always driven how medical claims have been paid… It really pays to understand what services you’re getting and how it’s covered by your plan,” said Krista Davis, an insurance agent with the Gremel Group.

Target 8 discovered billing advocates and other health professionals estimate up to 80 percent of medical bills contain errors. And a study in April 2016 showed the problem could be getting worse. Nonprofit Medical Billing Advocates of America says it finds errors on three out of four medical bills it reviews.

Davis points out many insurance carriers now have online resources and suggested patients use them before each doctor visit.

In November 2014, Target 8 discovered one of the first cost estimators to go online as an industry-wide transparency movement got underway. United Healthcare’s online tool shows what you’ll have to pay out-of-pocket for procedures or even a simple office visit.

“Utilize the tools and resources that carriers provide online and certainly become aware. I think that there is some responsibility that we have as patients, too,” Davis said.

Ramirez still hasn’t seen the codes that were submitted to his insurance company for his annual physical.

“What type of coding do I need to have the doctor code it so that it’s covered at 100 percent, because we’re going to go through this game all over again next year. It was right last year,” he said. “For as many times as I had to call, half of me was like, you know what, it’s not worth my time. Just pay the $158 and make it go away. But I’m thinking of all the other people that they’re doing this to.”

“People need to question,” Marie Ramirez added.

The Ramirez’s certainly aren’t the only ones questioning their medical bills. They can be confusing. While every medical test, even every concern you bring up to your doctor has a code, those codes are very specific.

For example, if you ask about a fall, there’s a separate code for a ‘repeat’ fall.  There’s even a separate code if you’re at risk for falling in the future.

“You can’t memorize the codes any longer.  It used to be with ICD-9, the old system of coding, you could memorize the codes.  You can’t memorize anymore just because every person, even if they’ve got the same illness, is going to have, probably, a different code,” Paula Hagstrom explained.

Hagstrom is an associate professor in the Health Information Program at Ferris State University who teachers her students how to code and knows medical bills depend on the codes’ accuracy.

“We use it for statistical purposes but more importantly for reimbursement.  One character could mean thousands of dollars or if you’ve got the wrong approach, a scope versus an open approach, could mean a lot of money,” said Hagstrom.

“One character could mean thousands of dollars,” said Paula Hagstrom.

The American Medical Association says error rates for commercial health insurers on paid medical claims dropped from nearly 20 percent in 2010 to 7.1 percent in 2013.

But even with significant improvements, the AMA estimates that more than $43 billion dollars could have been saved if commercial insurers had consistently paid claims correctly.

“You can get a whole room of coders and you’ve given them the same case study or scenario and they may be close but they’re not always going to be the exact same code. That’s why it’s important that (patients) read their bill carefully.  Ask for an itemized or detailed bill where every item is detailed,” Hagstrom suggested.

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