Introduction: How to Challenge Medical Bills
Medical Bills. The process is overly complex and it feels intentional. It's unfortunate but a reality of our healthcare system.
Here's my approach to navigating bills for the world's best branded hospital - The Mayo Clinic.
The important things to remember:
- Doctors provide care for patients... administrators interpret the doctor's notes and send you a bill
- CPTs are the codes used to categorize care and process bills. Get Familiar!
- A hospital (Mayo) doesn't necessarily lie... but they also don't hesitate to make up 'policies' as they go!
- You don't know everything on day one. To really get things adjusted you will have to learn your hospital's admin processes... here I layout how things work at Mayo
On a personal note: We are fortunate to simply be dealing with routine care. All the best to you and your family if you are dealing with medical billing on top of trauma or disease.
- Pile of insurance paperwork and invoices from your provider/insurance company
- Access to your medical records or M. A patient portal or print outs from your visits.
Step 1: Take Notes
Looking back I wish I had notes from my first call to schedule my first doctor's visit.
Please take notes. Healthcare professionals do. And what they write is the basis for what gets billed. Whenever possible capture quotes.
- Name, Date, Time (on/off), Department, Supervisor (typically a group), Direct Number
- Questions Asked + Responses
- Who they refer you to talk to next... they always try to pass off to someone else
- Policies referenced... where the printed version can be found. Ideally online. ---Mayo has never shared any written policy. Policies are contradicted with each call. Effectively I equate Mayo Policies to Lies...
Signing Notes. When talking to an administrator I've never actually asked but if I had to start over I'd have had people I speak with sign off on my notes... I'd make them take the time to hear me read things back and physically sign. Not with healthcare professionals... but too often administrators make up their own version after for internal review. Either omitting details or changing things entirely to suit their needs. --more on that later
--Not jaded... I just don't like being lied to.
Step 2: Understanding an Invoice: CPTs
Current Procedural Terminology Codes or CPT codes.
The language of invoices are CPT codes.
If you hope to have any success you have to be willing to understand how they are assigned and what they mean.
Assigning Codes. How they are assigned is overly complex. The medical professional doesn't deliver care by selecting from a shopping list of CPT codes... they use their expertise to help patients. On the backend - care is interpreted by hospital administrative staff. These staff members read through notes and select CPT codes to process your bill.
Interpreting Codes. There are a number of tools. The easiest way I used over past year was decisionhealth.com's code selector. It's now a paid service. A shame. Another paid service is emuniversity.com, but you can get around that by googleing "emuniversity" + "cpt xxxxx". If you need the definitive source the American Medical Association publishes an annual book of current CPT codes: CPT Professional 2020.
Step 3: Understanding an Invoice: CPT Example
Here's an example of a typical office consult with a specialist...
There are five levels. The codes for an office visit are 99241, 99242, 99243, 99244, 99245.
The doctor isn't assigning a level. They are writing a note and providing care.
The administrator than gets to pick the code!
The amount you are billed is subjective... That's right. And that can lead to a cost difference from $100-$1000 for even everyday visits. It can be much more if you are dealing with trauma or disease. The doctor's notes don't keep track of time but if you do you can use that to contest a billing.
Yes, this gets a little intense... In your notes track when a professional enters and exits the room. If they like to shoot the breeze note how long they chit chat before talking about what you are there for... you shouldn't be paying to hear their story.
----I had a 20 min consult come back as a level 4. Fortunately I could track text messages before and after my visit. More to come on how to challenge...
Step 4: Understanding an Invoice: Insurance Categories
Insurance coverage breaks down into different categories. Preventative, Labs, Emergency, Physician Visits, Inpatient, Outpatient, Continued Care, Maternity, Mental Health, and more.... there can be long list depending on your insurance.
Each category is covered at different rates and can factor differently against your deductible.
Doctors visits and labs are some of the most common care provided. It can also be subjective on where these costs fall.
Example 1: What is a cholesterol check? I thought it would be a lab... no. It's preventative. Annually under my insurance I can have one cholesterol check. $0 charge
Example 2: In contrast... any urine-analysis. No mater how much it could be seen as preventative by the doctor will count as a lab. 80% charge
When in doubt call your insurance company with the CPT code for the procedure being scheduled. ---if you are a patient at Mayo call OMC (Olmsted Medical Center is the neighboring hospital). Even if you pay out of pocket your out of pocket payment after Medica pays 20% will still be half what you would pay at Mayo. OMC Billing Dept can look up codes and give you pricing over the phone and negotiate.
These tests are all the same (a commodity) Mayo is 10x the size of OMC and should be able to charge less... but the Mayo brand allows them to charge more!! A good rule of thumb... nothing is less expensive at Mayo.
Step 5: Hospital: Relationship With Insurance
Each hospital negotiates with insurance companies... and individuals.
Insurance companies pay hospitals a lot of money in a given year. The bigger they are, the better the rates. Some employers are also able to negotiate direct.
Mayo & Medica
Mayo is self-insured... that means they are big enough to operate an insurance company that they own - Medica. Mayo sells insurance through Medica and provides Medica as a benefit for employees.
The problem. Being self-insured means that they don't have to negotiate with anyone. A Blue Cross or an Aetna expects to have have a say in pricing based on national standards. They also will contest individual invoices that don't make sense. Mayo doesn't want to deal with any other insurance companies. In fact, they really just want everyone to pay cash.
Having Medica means you have to do all the work yourself. No company is on your side sharing in the unnecessary charges and willing to contest a bill.
As one Mayo Administrator helped me understand... "Mayo doesn't mind double billing because it's really just moving money from one pocket to the other!" ---this is criminal! On top of the tax issues they are in effect stealing from people by not ensuring that bills are delivered properly! ---yes, always take notes
Destination Medical Center or DMC
Mayo prides itself on being a destination for medical care... what that means is that it gets patients who are willing to pay cash up front for services from all over the world because the Mayo Brand = Health. Mayo uses it's scale to deliver faster service and have professionals that communicate better between departments because they are better integrated than 99.9% of hospitals. Mayo is an example of how a system can be better by consolidation (there's a larger conversation here about socialized medicine and the positive and negative impact. also the cultural trade offs for the institution). But as a local expect to pay more for everything.
Step 6: Hospital: Departments
Yes, it's complicated. Overly so and I believe it's intended to burn patients out...
- Patient Account Services (844-217-9591)
- Office of Patient Experience (private pay, 507-284-4988 / employee ins, 651-267-5073)
- Estimating (#4 at Financial Counseling Center, 833-479-5483)
- Business Office
- Primary Care / Specialty Departments / Laboratory & Testing
- Departmental Review Boards
All of these groups potentially provide useful information but only one is likely able to adjust your bill. A Patient Account Service Manager is the person you need to change your bill at Mayo… they are not all created equal.
Know that each department will not hesitate to tell you that another has given you the wrong information. They also are all working off a basic rules of customer service:
- Don't share information unless specifically pressed to share.
- Nothing in writing.
- Protect the Mayo Brand.
- Collect, Collect, Collect.
Don't get too frustrated. We call this all part of our 'Mayo Journey'. It's just like talking to an airline... you have to know the system is not built in your favor.
Step 7: Department: Patient Account Services
Patient Account Services is the only department that can change your bill. The front line staff have no interest in making a change... they are there to collect.
In my experience about 10% will actually listen to an issue. The rest will simply nod along and try to send you off to a different department:
- 'have you asked the physicians office to review?'
- 'you'll probably want to talk with your insurance company about that...'
- 'that sounds like a coding issue, do you want file a coding complaint?'
- 'wow, that's very frustrating... do you want to pay now or can I set you up on a payment plan?'
No. The front line staff don't really listen. But you must listen to them. They can talk you through a lot of processes if you ask very direct questions. Specifically before letting them file any challenge you must get them to explain every part of the process. More on challenges under coding dept.
Patient Account Service Managers
About 30% will actually hear your issue and can make a resolution. It certainly takes more time than you want to learn the processes and find a person who will listen.
Always remind the managers that you are not frustrated with them personally but with the system you are all working in. They know that information is shared poorly. And about 30% want to help where they can. Get them to see your billing issue as one they can solve.
What they can't change:
- CPT Coding
What they can change:
- The value of the bill. They can adjust the amount but need a reason. They can even go to zero.
- Technically they can even make a courtesy adjustment without documentation. This has only happened for me when they are too lazy to fully document the issue and want to simplify their paperwork.
Step 8: Department: Office of Patient Experience
This group sounds like a good one...
Office of Patient Experience is her for the high net worth patients. People who come to the clinic and pay out of pocket. They are not here for locals. There is actually a separate remote department that handles issues for locals.
For high net worth:
Office of Patient Experience has a magic wand. They can change invoices. They can get doctors, nurses or even the CEO to call a patient personally to apologize or correct an issue.
The same rules apply as to the Office of Patient Experience... Protect the Brand. Collect.
Yes, they may submit a request for review or type up an internal note to a department. But don't expect any follow up. Also, don't expect to see anything in writing. Nothing they do is ever shared with patients. It's a complete black box.
In my experience... I was able to get a few notes read back to me from what was submitted on my behalf... this was early in my experience with Mayo... a real rookie move letting an Admin type up my formal challenge. They left out all the important information and honestly made it sound, even to me, like there was no issue. If you do walk through any submittal process with Mayo make sure your own write-up is included.
Step 9: Department: Coding
The Coding Department is often referenced by Patient Account Services. Really by all departments.
The Problem. No one can actually speak with coding.
That's right! It's the essential administrative task that has the most impact on how bills are created and processed. Yet there is no number, no address, no person. Simply a formal process for submitting a challenge to the department.
A Coding Challenge. This is Mayo's opportunity to use very resource to defend itself and make sure you pay the amount they want you to pay. It isn't a way to really question the bill. A coding challenge is the last step though everyone wants you to see it as the first!
No you need information before you can even begin to think about a coding challenge. If you are new to the process it's like a kindergartner challenging a college student. Only for the most blatant issues can you hope to win the challenge... and in those cases Patient Account Services should be able to help you over the phone (eg. double billing.
As with any formal submitted make sure you type up what you want submitted. If you don't think you need to ask the person to read back what they plan to submit on your behalf before they hit send. It won't be what you told them!
Step 10: Department: Financial Counseling Center
Here you want to #4 for estimating department.
Actually took me a long time to find estimating.
The staff here are no nonsense and without the same agenda. They can simply look up codes and don't have responsibility to care if you are paying or not.
Before I found this estimating department my first call was to OMC. There Patient Account Services and Estimating are integrated in a Billing department that can review everything at once.
I still call OMC because they can tell me what services cost at their hospital. It lets me know right away if I've received a crazy bill!
Real People. They are also real people... meaning if I ask about a CPT they can tell me that it's one they get all the time... or, one they don't typically see.
Catching Over-charging. That's important because most codes for general care come up regularly... Mayo, however, throws in random ones that allow them to appear like they are charging for a service you had but actually up-charging for something rare!! something any real insurance company would catch in a second!
Step 11: Department: Medical Review Team
The medical review team is there to review the decision making that lead to something that shouldn't have been ordered. Just like the coding department... they don't exist for you the patient...
This comes up when something was ordered that shouldn't have. Not as simple as a coding error where something is miss-classified.
It implies that someone did something wrong. Not necessarily. It doesn't have to mean blaming a medical professional. Mayo has all kinds of internal 'policies' for when they should order tests. Many times these tests are recommended before you visit a specialist...
If you aren't savvy... as I wasn't. You may accept one of these tests. Don't!
Always question the need for a test/xray/lab with the medical professional who will use the information.
Example: I complained about sinus headaches and wanted to ask questions related to mold exposure... maybe talk to an allergist? I had no family history of allergies but yet a full allergy panel was run. My mistake. Now I let them even run their allergy panel was crazy... but it was my first experience at Mayo and admittedly I was impressed by the Mayo Brand. The bill was right around $890. Medica wouldn't pay for any of it. There is a long story here about the medical review team and the policy of having an alergy panel whenever anyone asks a question about an alergist... completely fabricated. The way this resolved was by calling OMC. Learning that a single mold allergy test under the same CPT as the panel should cost $8.80. From there a Patient Account Manager was able to adjust the bill to $8.80.
Step 12: Department: Business Office
These folks are really just there to collect payment. They will listen to your story and share frustration. They can also direct calls to Patient Account Services... but that's it.
Tier Reset: What they can do is reset the tiers for your bill. Mayo has a system of escalating a bill to collections. They progressively send nastier paperwork at each tier. If you don't specifically ask for the the tier to be set to level 1 you'll automatically escalate each month.
Formal Paperwork: All paperwork you'll receive from the hospital is meant to formally conclude a process. It doesn't actually mean anything. It's either an attempt to dismiss an issue or intimidate you to simply pay the bill. It can be stressful.
Step 13: Department: Medical Practice + Notes
Patient Account Services often tries to get you to review with the medical staff that provided care... the reality is that the notes contain the information that coding uses to create your bill.
You need to have these medical notes available and you need to trace the bills/CPTs back to the notes. When they don't connect you are being over-billed.
Step 14: Invoice Issues: Each CPT Individually
Visits are billed as it's own invoice made up of a series of CPT codes.
At times line items show up without the CPT code... this is an error.
Get all the codes. Look each one up.
When you call address only one CPT at a time. The administrators aren't able to handle more than one issue at a time.
Structure Helps: One day a week.... I will only make calls related to billing issues on 1 day a week... say Tuesday. I tell the people at Mayo this and they have to call me back on Tuesday. For your own mental health and to avoid burnout you have to set your own rules for them. Time is on your side if you can avoid burning out... Yes it's frustrating but as long as you are actively working through an issue the invoice can't escalate and it certainly can't go to collections.
Step 15: Invoice Issues: Double Billing
The easiest issue to resolve.
Any front line operator at Patient Account Services can take care of this. Start with the easy ones first.
Note on needle insertion: It always shows up multiple times if you have more than one lab test. These should always be removed. It's an extra overhead charge they like to bill to inflate gross billings… The reality is you should never pay any needle insertion fee... there are plenty of preventative tests that could be run at the same time as other labs... ex. if you have cholesterol checked at the same time as labs the insertion is considered preventative and waived.
Step 16: Invoice Issues: Coding Errors
Again, the Coding Department is responsible for a significant part of the over billing.
If coding can interpret something in the medical notes as anything more expensive (at Mayo) they will always bill for the more expensive code. Believe it! You need to lookup the code they used and have a good resource to find the related codes. Google more than you think necessary and find a free site that gives you the related codes. Or, you can always buy the CPT code book. Honestly knowing the codes has saved me over $1000 in the last three years. But there are free sources online. A lot of medical systems provide a list of their codes... they tend to be smaller rural systems.
Ok - here's what I found on a quick search... Not bad Utah... health.utah.gov/stplan/lookup/CoverageLookup.php
Step 17: Invoice Issues: Unneccessary Tests
Unnecessary tests was mentioned earlier regarding Medical Review Team.
It's a difficult issue because you're asking the hospital to admit they did something questionable (wrong)... The fact is they did but they aren't going to own it. They've created policies to make money and justify the need for services.
Related to my example with the allergy panel... I was told it's Mayo's policy that when a patient asks about an allergy issues before anything else can be discussed the patient must have an allergy panel. That's crazy!
Do your best to stay ahead of the tests. If it's already done you have to look back to the notes and understand related CPTs. Chances are when something is run that wasn't needed they looked past a series of other tests that could have cost less.
Step 18: Invoice Issues: Fabricated Items
Yes. This happens.
Things just show up on your bill for no reason. More often it comes from a negligent Coding Department.
Avoid a Coding Review... get the Patient Account Services manager to read through the notes themselves and see that it needs to be removed. They can do it but it takes effort on their part.
Here's the classic example:
Something you discuss with the doctor shows up in your notes... perhaps discussing the possible side affects of a treatment or potential false positives of a test... The coder simply notes the item as something you need to pay for because they spotted it in the note... not catching the full detail.
There is something predatory about the whole process but most acutely in the Coding Department.
Step 19: Invoice Issues: Market Pricing
Hospitals 'should' have pricing that's competitive with other hospitals in the market. Unfortunately that is not the case. Mayo won't adjust off the pricing at OMC. You can however learn a lot from how OMC structures pricing. Also cost codes often have variable costs. Mayo will bill the most they can everytime... the OMC billing department may help you understand how costs can be less. ---as was the case with my allergy panel example.
Your adjustment. Again, it takes the right person but a patient account services manager can adjust pricing down within the CPT code.
Crazy Mayo Example... a Mayo admin told me it's not uncommon for customers to receive a higher bill if they have mayo insurance than someone who pays out of pocket because it's helpful to the patient to work more quickly to max their deductible… simply non-sense they made up on the phone
Step 20: General Notes: Pre-visit
Shop Around. Even if it's out of network depending on how close you are reaching a deductible it may be better to pay cash at another hospital. Either way you'll learn from calling the other hospital.
Verify CPTs. Check procedures in advance and confirm they are covered… often there are similar CPTs and you could just need to make sure things are ordered properly. Insurance companies can be more helpful before you have care. They also aren't in a position to contest anything and can speak more freely.
As always - take notes!
Step 21: General Notes: State's Attorney General.
Each State has their own rules.
Check your state's Attorney General Page. Here in MN there are actually really good resources.
This page, https://www.ag.state.mn.us/Consumer/Health/Default.asp, goes into more detail about billing and collections. Click on a few states. You may find it helpful. It also doesn't hurt to call.
Step 22: General Notes: Complaints
The fact is no one at the hospital cares... it's just not in their interest.
The one time I asked to escalate my complaint after talking with the Patient Experience Office I was sent a copy of the '07 Minnesota Bill of Rights. This is something that's published every year but apparently '07 is when Mayo thinks they nailed it!
Basically... they let me know that I should file a complaint against the physician's Medical License. Terrible. They were completely willing to sell out a physician when my complaint was about the hospital and their processes.
The real course of action is to file a complaint with the state's attorney general.
Step 23: Good Luck!
Appreciate you reviewing this rather long instructable... not sure this is the right forum but it's my favorite!
Hope you are a bit more prepared for medical bills. I'm sure in the coming weeks I'll make a few adjustments. I've tried to share some personal examples without getting into too much detail. Any feedback is helpful as I refine.
Please know that even now I expect 7-10 calls to follow up on each visit/invoice with Mayo. It isn't a simple process. We joke that it's part of our 'Mayo Journey'. They like to brand themselves as 'Patient Centered Medicine' and use fuzzy language about the 'Patient's Journey'. Clever right!
Nothing about the experience is patient centered. It's 'Mayo Centered Medicine' or more 'Coding Centered Care'.
As always don't buy Brand. Brand is a shortcut not to think... Mayo like too many use a Brand to build trust that can be used to overcharge.
Good luck and if you have any questions I'll follows the posts!