Case Studies

Reviewing Medical Bills Pays Off!

  • A large self-insured corporation with 1,000 employees received a negotiated $375,000 settlement.
  • A hospital billed an individual $186,000 for 200 heart valves when only one was used.
  • Unbundling medical codes and other errors in a medical clinic led to overcharges of $708,000.
  • A TPA missed a $10,530 overcharge for a semi-private room that was billed as an ICU room...over $2,000 per day difference.
  • A typo on a procedure resulted in an overcharge of $10,000.
  • A TPA paid a large claim to a hospital in full less a 2% negotiated prompt payment discount.  In reviewing the claim, it was found that there was an existing PPO agreement in effect, however, it had not been properly loaded into a file during a system conversion. Over 80% of the claim was reimbursed.
  • 1,144 hospital bills reviewed between 1992 and 1994 found that 859 (75%) of the bills had significant overcharges which totaled $891,655.81--an average of $1,038.02 in overages per bill.
  • A patient received six radiation treatments but was charged for seven--a $4,000 error. This same patient was billed for two "initial" visits, each more than $100.
  • A bill reviewer in Roanoke, VA reviewed 300 hospital bills and found errors worth $300,000.

What the media has to say:

Money Magazine: "Want to know one reason why medical care costs so much today?  Doctors and hospitals have become the gang that can't bill straight... More than 90% of the roughly 31 million hospital bills processed each year are wrong, with overcharges making up an estimated two-thirds of the errors.  The cost of overcharges to consumers, insurers and government-the biggest medical payer of them all - is an estimated $10 billion a year."

The Washington Post: "...the medical billing process makes little sense from a consumer's perspective. One surgical procedure will generate a bill from the hospital, another bill from the surgeon, and more from the radiologist, the anesthesiologist and maybe a pathologist. Then there are those pesky pricing codes, attached to everything from a lataex glove to a cotton swab. One slip of a keystroke by a billing clerk can dramatically alter the tally."

Consumer Reports: "Five percent of the 11,000 people recently surveyed by Consumer Reports said they discovered major mistakes after examining their hospital bills. The patients with $2,000 or more out-of-pocket expenses, meaning those costs not covered by their medical plans, were twice as likely to uncover errors."

Forbes: "If you have to pay some of your hospital bill, check it carefully. Neither the hospital nor your insurance company will make this easy...Hospital robbery."

Consumer Reports: "THE NEED FOR VIGLIGANCE. Making sure that you are charged correctly is not easy. Health insurers have a different contract with each hospital that spells out how much they will pay; so there's no single fee schedule a consumer can consult. Calculating the part of the hosital bill for which you are responsible would be difficult under normal circumstances. Now imaging trying to track services received when your or a family member is unconscious or heavily sedated. Even if you were conscious, knowing, for example, wheter you should have received five IVs or two in the space of eight hours is virtually impossible unless you are a medical provessional." "...any overcharges will cost you. Money siphoned off by errors or fraud can chip away at your lifetime total."

Philadelphia Daily News: "Most hospitals charge patients for treatments, services and supplies before they actually are received.  If the treatments or services are never rendered or the supplies not received, because of a change in the doctor's orders or an early discharge from the hospital, the charges usually remain on the bill."

Wall Street Journal: "Some Health Insurers Leave Patients to Foot Excessive Copayments."....."Although insurance companies frequently complain about being duped by fraudulent policyholders, Trigon and dozens of other health insurers and managed-care providers stand accused of a secret discounting scheme to siphon millions of dollars from their policyholders.".....

The Washington Post: "The errors exacerbate consumer frustration with an already troubled health care system. Those lucky enough to have insurance find themselves digging deeper into their pockets to pay premiums, deductibles and co-payments. Some dig so deep that they ruin their credit: Medical debt now ranks as the second-leading cause of personal bankruptcy in this country, after credit card debt. About 80% of families in bankruptcy due in part or in whole to medical bills were insured, a recent New York Law Review study found."