Case Studies

Case Study #1

Situation:

Patient had shoulder surgery in 2016. Surgeon advised patient to return every two weeks for follow up visit and an X-ray. Patient was asked to pay copayment for each follow up visit, which she did at $75.00 each time. She followed up with the surgeon four times after the surgery and paid $300.00 in total copayments to practice.

Research:

Patient contacted Big Medical Bills who immediately saw a mistake was made by the surgeon’s office.  Every procedure has a “global period” which constitutes a time frame where all visits are included in the fee paid for the surgery. In this case the X-rays were also included.

Resolution:

Big Medical Bills contacted the physician’s office after receiving written approval from the patient. We explained the “global period” to the office staff and they said they would speak to surgeon. The surgeon agreed an error was made on their part and a refund of the $300.00 was made to patient.

Case Study #2

Situation:

A woman contacted Big Medical Bills concerned that her husband’s bills for surgery were very high and unreasonable. The patient had colon cancer and was seen at a leading hospital in a large metropolitan area. The patient has bills totally $220,000 after insurance paid what they were supposed to pay. The charges owed were predominantly for deductibles in an out of network scenario.

Research:

Big Medical Bills was asked to review the bills for accuracy in both billing procedure codes and diagnosis codes. We found egregious errors in coding of the procedures as some of the codes are considered attached to another procedure performed, or global. Because the physicians were out of network they thought they could balance the bill for all they billed to the carrier, who eventually denied the majority of the claim and put the responsibility on the patient.

Resolution:

After the procedures were recoded and sent back to the carrier for reevaluation, the patient’s final responsibility was reduced to $2,000 which they were happy to pay.

Case Study #3

Situation:

Five Medicare patients in Florida were receiving bills from their doctor and paying them regularly.

One of the patient’s two daughters were auditing their mother’s check book and noticed many checks made payable to the doctor’s office. They knew their mother had good insurance, Medicare and a good secondary carrier, so they questioned all of these bills. Through a friend in Florida, they contacted Big Medical Bills to look into the matter.

Research:

Upon receipt of the paperwork from the patients and the necessary HIPAA forms we contacted the doctor’s office and requested the billing and payment history for these two patients. They were reluctant at first but we advised them that if fraud was being committed and the paperwork was not turned over, the penalties from Medicare would be severe.

Upon review of the Explanation of Benefits for the Primary and Secondary we found patients being billed for non patient responsibility items. Also in some instances the patient was billed for the 20% co-insurance, before they even sent the claim to the secondary carrier.

Resolution:

We advised the physicians of our findings and the potential fraud issues. They admitted they had no knowledge of this and would immediately look into this matter. In one case the physician fired the billing manager and a front desk person who were involved in this fraud.

Since we intervened the patients have not received any bills other than bills that they are responsible for. Most importantly, the physicians refunded every penny to the patients within 10 days.

Case Study #4

Situation:

Patient was experiencing abdominal pain and was advised to go to the local urgent care center. They evaluated the patient and advised the patient to go to the emergency room at the hospital. At the emergency room they determined that the patient had issues in the abdominal region and they admitted the patient. After two days of testing it was determined that the patient had a gallbladder attack and needed surgical intervention.

Without advising the patient the hospital brought in the surgeon on-call to evaluate the patient. Surgery was advised sooner than later.  The surgeon in this case was out of network of the patient’s plan and the patient was never advised of this.  Surgery was performed and the outcome was good. Patient was released from the hospital after paying his in-network copayment.

The surgeon submitted a bill to the patient’s insurance company for $70,000 for his services and $70,000 for the assistant surgeon, who in this case was a physician’s assistant, not an MD or DO. The patient was understandably floored by this bill.

The surgeon would not speak to the patient in regard to the bill and the staff was very unsupportive of the patient in regard to the bill as well. The surgeon eventually sent the claim to collections and was awarded the decision. The sheriff issued a warrant to seize assets and garnish payment from the patient. The patient was recently divorced and his life was in chaos. He was able to pay about $3,500.00 to the sheriff against the bill, and could not pay any more. He was on the brink of filing bankruptcy when he contacted Big Medical Bills for help.

Research:

After reviewing the claim with the documents sent by the patient, Big Medical Bills immediately found glaring errors in this matter.

The assistant surgeon, whether a physician’s assistant or a doctor, can only charge 18% of the amount charged by the surgeon. Secondly, the maximum national average for reimbursement for this surgery is $9500.00. Medicare allows $965.00.

After receiving permission from the patient and the proper HIPAA paperwork filed with the doctor’s office, Big Medical Bills finally spoke with the surgeon about this matter and hoped to resolve it to the satisfaction of all parties.

There are laws in certain states that dictate that out of network providers must notify the patient that they do not accept their insurance and have them sign a waiver understanding that they will be getting a bill for any patient responsibility. In this case, this did not occur.

Resolution:

Big Medical Bills finally settled with the doctor for $7500.00, inclusive of the assistant surgeon’s fee. If the surgeon did not settle, he could have been brought up on billing fraud charges for billing the assistant surgeon at the same rate as himself. He understood all and signed off on the settlement. The sheriff was notified and the matter against the patient was dismissed.  The patient never had to file for bankruptcy.

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