Billing errors cost members and employers on services

As many as 80% of medical bills in the United States contain errors, according to Derek Fitteron, CEO of Medical Cost Advocate, a partner of ClaimLinx. And those errors can lead to an unnecessary increase in a bill’s overall cost. In fact the credit agency Equifax reported that for bills totaling $10,000 or more, there is an average error of $1,300.

A big reason these errors occur is the way healthcare providers classify diagnosis, symptoms and procedures. They use a coding system called the ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification). The system is incredibly complex with mistakes leading to patients potentially being charged for procedures or testing they did not receive or more expensive versions of their care.

Errors can occur on any medical bill, but tend to be found on bills for complex medical procedures, inpatient care, care from a medical specialist or when patients receive care at a facility outside their insurance carrier’s network.

To prevent this issue for all ClaimLinx clients with a Medical Expense Reimbursement Plan, any high dollar medical claims are automatically sent to Medical Cost Advocate for review and negotiation. But employees can also help to combat this issue by being sure to check any medical bills for procedures or testing they do not recognize, especially bills totaling over $1,000.

Members should contact their provider first with questions about any bill. Then if a change must be made to a previously processed claim, they can contact the Claims Department at

Some of this information was taken from an article which featured our partner, Medical Cost Advocate, published in Employer Benefit News. Read the article.


Physicians Lack Tactics for Discussing Medical Costs

It’s never easy to talk about financial challenges. But when the topic is avoided when doctors are talking about medical costs, the consequences can be life threatening.

In an effort to quell this issue in the future, a study published recently in Healthy Affairs explores the dynamics between physician and patients when talking about finances. The study examines the question “are physicians prepared to help patients factor out-of-pocket expenses into medical decisions?”

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It’s a topic that becomes increasingly important as patients are saddled with shouldering more of their own healthcare costs. In theory, the increased financial responsibility is supposed to make patients sharper consumers and empower them to trim unnecessary spending.

However, previous study has shown increased costs often lead to people skimping on both valuable preventative care as well as superfluous diagnostic and treatment services.

This study recognizes that doctors could play a key role in helping patients find appropriate, affordable care by talking more about the out-of-pocket costs. But a lot of work would need to be done to achieve this change, according to the study.

“We need to prepare physicians to hold more productive conversations about health care expenses with their patients,” Peter Ubel, the study’s main author and a physician and behavioral scientist at Duke University, said.

For the study, researchers analyzed transcripts of nearly 2,000 physician-patient conversations regarding breast cancer, rheumatoid arthritis and depression treatment. They identified instances in which patients suggested the care might be too expensive and assessed how doctors responded.

Researchers found that overall physicians dismissed patient’s financial concerns, either by not acknowledging them at all or by only half-addressing them.

For example, if a patient pointed out how expensive a drug is, the doctor might ignore the comment completely or might only suggest a temporary solution – like a free trial – without exploring long-term strategies to address the problem.

And, without a long-term plan, patients may eventually stop taking the medication, or take it irregularly. That can harm their health, resulting in a potential costly hospital visit.

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Changing doctors’ behaviors likely won’t be easy, as this is a relatively new aspect to an age-old position. Physicians have not traditionally been taught to listen for patients’ pocketbook concerns, and when they do register, doctors are not accustomed to talking about cost barriers. Many might even think it’s inappropriate to bring up money at all.

Another hurdle for this conversation is that physicians are not always aware of a procedure or medication’s cost. They may be just as surprised as the patient by the high price tag of some drugs and services.

“It’s not as though, ‘Oh, it’s just consumers can’t figure it out.’ Doctors don’t know,” Jonathon Kolstad, an assistant professor of economic analysis and policy at the University of California Berkeley, said. When it comes to figuring out what a drug will cost, “doctors are in the same boat.”

Hospitals Will Pay $28 Million for False Medical Claims

The U.S. Justice Department is cracking down on hospitals found purposefully billing Medicare incorrectly for their own profit gain.

Thirty-two more hospitals located in 15 different states agreed to pay the U.S. government more than $28 million to settle allegations that they billed Medicare for kyphoplasty procedures as inpatient rather than outpatient services to make more money.

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Among the facilities that recently settled are the Cleveland Clinic, which will pay $1.74 million, and five hospitals in the Community Health Systems, which will pay $3.5 million.

These settlements are the latest in a long-running whistle blower lawsuit that alleged Kyphon Inc. encouraged hospitals to perform the kyphoplasty procedures as inpatient rather than outpatient in order to help pay for the kits used in the process.

In all, more than 130 hospitals have reached settlements with the U.S. Justice Department totaling $105 million.

Kyphoplasty is currently considered a minimally invasive procedure used to treat certain spinal fractures often caused by osteoporosis. In most cases, the procedure can be performed safely and effectively as an outpatient procedure without the need of a more costly inpatient hospital admission.

Benjamin Mizer, head of the Justice Department’s Civil Division, emphasized how these purposeful errors “waste the country’s vital health care dollars.”

“The Department of Justice is committed to ensuring the Medicare funds are expended appropriately based on the medical needs of patients rather than the desire to maximize hospital profits,” he said.

All but three of the 32 hospitals that recently settled were named as defendants in the previously filed whistleblower lawsuit. Craig Patrick, a former reimbursement manager for Kyphon, and Charles Bates, a former regional sales department for the company, filed the lawsuit in 2005. The two will receive about $4.75 million for the most recent settlements.

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The government also previously settled with Medtronic Spine LLC, the corporate successor to Kyphon, for $75 million.

The case stands as an example of the importance of regulation and vigilance in the health care sector, an industry where billions are spent annually. It remains important not only for the government to investigate the country’s spending, but also for citizens to be responsible consumers and ask questions about the medications and procedures performed.

Online Tool Helps Consumers Compare Hospitals

When preparing for an elective surgery, it’s important to research which hospital provides the best care for that particular procedure. Thanks to U.S. News and World Report, that just got a little easier.

This month, it released the “Best Hospitals for Common Care” tool, which provides ratings for 4,600 hospitals in the country, evaluating the facility on five common surgical procedures and medical conditions.

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It evaluates three common surgeries: heart bypass surgery and hip and knee replacements. Together these procedures account for 1.4 million surgeries per year, according to the Center for Disease Control and Prevention.

Also included in the evaluation are two common chronic conditions: congestive heart failure and chronic obstructive pulmonary disease. About 5.1 million Americans have heart failure and about 15 million have been diagnosed with COPD, according to the Center for Disease Control and Prevention.

The tool is an encouraging step towards more transparency in hospital procedure so that consumers can make informed decisions about where they are treated.

“We are now on the cusp of being able to provide consumers with concrete, hospital, level, very specific information about volumes and performance,” Ben Harder, chief of health analysis for U.S. News and World Report, said.

According to U.S. News’ analysis, about 10% of hospitals rated in each condition were high performing, and another 10% were low performing. Only 34 hospitals received high performing ratings in all five procedures and conditions.

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Harder said the next step for this tool is to expand it to include more procedures and conditions, a goal he says will be reached as soon as 2016. It’s a vital resource consumers are in immediate need of.

“If you’re going to get an elective procedure, you generally have time to do research,” Harder said. “And if you’re going to choose, you should have full information about how experienced the hospital is treating that condition and how good their performance measures are.

Report Shows Lacking Mental Health Services Coverage

As of the end of the 2014 open enrollment period, 15 million Americans who did not have health insurance before the Affordable Care Act now have coverage.

It’s a significant victory, bringing the total number of uninsured adults from 18 percent to 12.9 percent at the end of the 2014 fourth quarter, according to Gallup.

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But a new report by the advocacy group Mental Health America suggests despite the major strides in overall access to health insurance Obamacare has provided, getting affordable mental health services may still be a challenge.

The report shows the prevalence of mental illness in the country:

– 42.5 million, or 18.9 percent, of adults in the U.S. suffer from a mental illness

– 19.7 million, or 8.46 percent, adults have a substance abuse problem

– 8.8 million, or 3.77 percent, adults report serious thoughts of suicide

The key finding of the report, though, is that despite the frequency of mental illness among U.S. adults, access to sufficient care is still an issue.

According to the report:

– Only 41.4 percent of individuals with a mental illness report receiving treatment

– 1 in 5 adults with a mental illness reported they did not get the services they felt they needed.

States with the lowest prevalence of mental illness and the highest rates of access to care are Massachusetts, Vermont, Maine, North Dakota and Delaware. Those with the highest prevalence of mental illness and most access are Arizona, Mississippi, Nevada, Washington and Louisiana.

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Paul Gionfriddo, CEO of Mental Health America, said he would like to see mental illness treated and covered more like other chronic conditions or diseases.

“We have to stop waiting until mental illnesses reach Stage 4 to treat them,” he wrote. “By Stage 4, problems are so advanced that even with the best treatments available, recovery is often compromised.”