My medical billing

[Tab]

I'm undergoing chemo for advanced cancer. These are snippets of the recent billing. My insurance (fortunately) picks up nearly all of it, but I'm having a hard time interpreting the bills. For instance, I had an immunoglobulin infusion that seems to be $22,000, but all of which was denied, yet I wasn't billed. Who picks up what in this scenario?

And what do you think of the billing overall? It seems wildly out of whack.

[REP]

1. The "explanation codes" might give some hints

And the rest: well, some of those things don't actually cost that much (that's just what they charge), and the rest will be paid by being billed into cash patients' bills, etc.

[Sekhmets Daughter]

2. What did expalnation #5 say?

[Warpy]

3. It looks legitimate to me, exactly what I'd expect to find

for any person with a central line who is getting chemotherapy through it. The drugs are far from cheap and the services rendered look appropriate.

There aren't any red flags for me like upcoding and unbundling lab work.

That's why some diagnoses are so ridiculously expensive to treat.

[uppityperson]

4. Call them and ask to find out wtf it all means. The big question is why was it denied.

Denial can be for a number of reasons and why it was denied is the key. Was it a double billing, or something they don't cover at all, or because your deductible wasn't met or ???? What were the "explanation notes" referenced down the middle of the EOB.

This looks like you are not liable for any of it, according to this bill now. I do some med billing, and interpret what they send to my clients, fwiw. Not an expert but do know some. I'd advise calling the insurance company for more information as to why it was denied and what this means for you. Have you heard from the facility where you got your infusion?

What seems out of whack here?

[Tab]

7. I don't know that anything is "out of whack"

I'm just trying to understand the process, with a subtext on the machinations of the medical billing/insurance process.

[cbayer]

5. A couple of things about this.

First of all, hospitals and other health facilities routine *bill* three times or more what they expect to get.

Second, insurance companies (and Medicare) often have agreements with providers to bundle some things. So, while the hospital may charge separately, some of the individual charges may be denied and paid as part of a bundle. In addition, they may have an agreement that they will not cover certain things and that you can't be charged for them either.

Hope that helps and that you are felling better.

[Tab]

6. Explanation codes

I didn't immediately know what they were, but looking them up, they seem to be:

1- Duplicate claim
2- Adjustment
3- Deny (included in allowance of another service)
4- Deny (service paid as part of major procedure)
5- Admin denial - Failure to comply with notification req's, no pt liability
6- Deny - Services exceed HPHC guidelines / policy/ med tech assess - no pt liability
7- Deny - Inappropriate code - Replaced

[uppityperson]

8. Good, thank you.

1. This was billed before, or processed already.
2. Facilities bill large amounts but agree to take lesser, which the insurance company decides is "usual and customary" and not so much.
3. Some services are bundled with others, which this looks like it is saying. For instance a place might break down a service and bill (for example) "iv therapy" or they may bill "iv catheter, iv insertion, iv tubing, someone to watch it all, janitor to stand by" and the insurance will deny some of that as included in other bits.
4. Same as 3 I think, but major procedure vs service.
5. Facility didn't write the right numbers somewhere, or didn't precertify need or a number of things ins co's pull out to not pay. This means it is not your problem.
6. There are guidelines as to what is considered "normal" or normally expected for a procedure. As life does not always follow the guidelines, often more is added and insurance will deny those bits. A smart billing person will figure out how to get paid for what was needed but not theoretically needed in a perfect situation (yes, I am ins jaded).
7. They billed the wrong code.

Insurance billing is quite a game and it can take several tries to get paid for what was done, to figure out how to send it through right. This is a notice to you on what's up in the game, but not a bill for you to pay. That all will come from the facility and all involved with your care. I hope this makes some sort of sense.