The kind of surprise no one likes – a medical bill

By Nedra Rhone, AJC

I was out of town when I received notice that a bill from a medical lab would arrive in the mail soon.

My first thought was that someone had stolen my identity, because I had never heard of the lab.

For the next hour, I logged in and out of my ID theft protection services. I’ve signed up for several over the past few years, courtesy of various companies trying to atone for numerous data breaches that exposed customers’ personal information. Seeing nothing suspicious, I tried to focus on other things and enjoy the last few days of vacation. But the mysterious bill still nagged at me.

When I returned home, the envelope was waiting. I ripped it open and learned the $258.68 bill was for services that had been performed by my medical provider in January 2023. Surprise! Or rather, surprise billing.

This isn’t a bill that would bankrupt me, fortunately, but I wondered why on earth I was receiving an invoice for services performed 15 months ago.

No claims from the company were shown in the explanation of benefits (EOB) from my insurance provider for the date of service. In fact, there was no mention of this company anywhere in my medical records.

So, I called the physician who provided the service.

The assistant who answered the phone advised me not to pay the bill, saying the lab has made a practice of unbundling services then billing patients for tests that already had been paid for at the contracted rate by insurance companies.

The assistant also said the physician no longer works with the lab and that, if I receive another bill, I should tell the company to contact the physician’s office directly.

I’m not alone when it comes to being confused by the medical bills generated by America’s patchwork health care system. It’s hard to imagine that the lab’s billing practices, as described by the office assistant, is above board. But, honestly, who can tell?

Clinical lab tests are at the top of the chart when it comes to consumers’ ongoing concerns about surprise bills, according to some industry reports.

Was the lab breaking up services into multiple codes for higher reimbursement? Was it also upcoding, or using more specialized codes than needed? Was the lab trying to get away with billing me for services never performed, also known as phantom billing? Or did the employees simply make a mistake?

I may never know the answer, but I do know we need more transparency in medical billing.

In a study by the Federal Reserve five years ago,more than 20% of American adults reported that they had received major, unexpected medical bills. Unexpected bills can take many forms, but some of the most expensive come from out-of-network providers whose services are contracted by in-network providers. Patients are not aware that they were even receiving out-of-network services until the bill comes.

The lack of transparency in medical billing can also make it hard to recognize a billing issue. If patients manage to wade through the web of codes and costs to discover something is wrong, they certainly will have to expend a lot more time and energy trying to find a resolution.

Many people know how to fight a mechanic or a contractor if they’ve been billed twice or didn’t get the services they paid for. Few of us are skilled at fighting the medical bureaucracy. At the moments when we are sometimes most vulnerable, we may choose not to wage war.

The problem is so pervasive that it actually forced bipartisanship in Washington. The NoSurprise Billing Act went into effect Jan. 1, 2022. That helped, but the issue is ongoing.

“Evidence shows the laws are having the intended effect,” said Liz Coyle, executive director of Georgia Watch, where staff has seen a reduction in calls related to surprise bills. “But that doesn’t mean there might not still be bills sent in error.” And that doesn’t mean there won’t be companies breaking the law, she said.

Under the law, out-of-network providers can’t bill patients for costs above the negotiated rate from insurance companies when patients are treated for emergency services or non-emergency services at in-network facilities. The health care provider and health insurance plan must negotiate payment through an independent dispute-resolution process. A Georgia law offers similar protections.

“Medical billing is just so complicated, and the federal law doesn’t cover everything,” said local patient advocate Cindi Gatton.

In short, the laws to end surprise medical billing haven’t ended it. But, in a broken healthcare system like ours, that’s hardly a surprise.