Heath Care Pricing Transparency and Consumer Rights: Checking bill accuracy

WHEN THE FIRST BILL ARRIVES (called a "summary bill") ...

• Contact the provider's billing office and request:
  • an itemized bill that includes the billing codes (called CPT codes and HCPCS codes).  Below is an example of an itemized bill showing the codes boxed in red.  Also watch for modifiers.  This example shows a modifier "25" on the code for G0383.  
  • ask for sufficient time to research the charges.  If the bill is "Due upon receipt," request more time.
• Download the "Explanation of Benefits" (EOB) from your insurance website patient portal.  Do not pay any bills from the provider until you are sure that your insurance company has received the claim and processed it appropriately.  We like this guide from the New Hampshire state government on what a patient should do if an EOB does not match a provider's bill.
• Obtain a copy of your medical record for the visit.  All charges on your bill should be traceable back to something stated in the medical record.  In other words, you should not have to pay for any services which are not noted in the record.

WHEN THE ITEMIZED BILL ARRIVES...

• Google the codes to determine their meaning.  Try sites such as Find-a-Code.com or CMS.gov.  Check your itemized bill for:
  • Inaccurate quantities billed
  • Services that didn’t actually happen
  • Charging for a more complex or involved service than what was actually provided (upcoding)
  • Charging separately for each component of a procedure that should be billed all-in-one (unbundling)
  • Inappropriate use of code modifiers to increase charges, such as 25 and 59
  • Check your bill for common types of fraud identified in Medicare/Medicaid claims 
  • More info on billing errors from Experian
• If you had a hospital stay, match up each itemized hospital charge to medical records to make sure there that the services happened in the quantities indicated.