HOUSTON - Unexpected and inaccurate medical bills can be alarming and shocking.
Whether it's hundreds or tens of thousands of dollars, when you get a bill for an ER visit or surgery you already paid or don't owe, it can sometimes be difficult to get answers from the provider or insurance company. All this week KPRC2 consumer expert, Amy Davis is helping with your medical bills.
There are some things you can do before any surgery or procedure to protect yourself. Untangling the twisted mess of an inaccurate bill after the fact can be daunting.
"The phone calls were threatening and they were menacing and they were harassing," explained Tom Boone, of the calls he received from the Memorial Hermann billing department after he had surgery to correct his flat feet. "They were basically saying 'Hey, the insurance company is not gonna pay for this. You owe the full amount. And we need you to pay it now.'"
Boone says the first phone call from Memorial Hermann came the same day he got home from the hospital even though he paid what the hospital and doctor told him were his portions of the bill before his surgery.
Even though Memorial Hermann pre-approved the procedure with his insurance company, Humana, after the surgery, the hospital said the claim was denied. They repeatedly sent Boone a bill for $21,224.00.
"I would make phone call after phone call after phone call," Boone told Davis. "All I could get was from Humana 'We're not paying for this.' And from Memorial Hermann, 'You owe the full amount.'"
"It can be frustrating and time-consuming," said Dr. Vik Rajan, a Houston medical billing advocate with Houston Patient Advocacy.
Rajan says what Boone experienced is not uncommon. To try and avoid it, you should get as much as you can in writing from your insurance company, the hospital and the doctor including pre-approvals and your co-pays.
"Because if there's any dispute later on, whatever you have in writing ... that's what's gonna protect you," Rajan explained.
"It could have been so simple, but they made it so hard," said Boone.
Humana finally paid Boone's claim 10 months after his surgery. All a Memorial Hermann administrator would say about pressing him for payment during that time was "I apologize that your bill was not placed on hold while these issues were being sorted out."
"I still don't know what happened," Boone told Davis.
One place Boone could have turned for help is a little-known mediation program at the Texas Department of Insurance.
If you receive a surprise bill from a provider and you can't get help from either the doctor or the insurance company, call TDI.
They will mediate between you and the insurance company.
In 2018, the program got $9.7 million worth of medical bills negotiated down to $1.3 million.
When we called Memorial Hermann to ask what took the hospital so long to get Boone's bill corrected, spokesperson Kathryn Williams sent the following statement:
"Due to patient privacy, I cannot comment on any specific patient interactions. However, generally speaking, it is common for insurance companies to impose highly strict coding requirements when approving certain procedures for payment. It is unfortunate when a patient may get caught in the middle, between those strict requirements from the insurer and how a physician or a facility codes a procedure. We applaud the Texas Department of Insurance’s efforts to provide more consumer forums to resolve billing issues when insurance companies deny claims based on technicalities. As for our system, we make every effort to work with patients when an insurer denies a claim, including coordinating with the patient’s physician and/or insurance company. We recognize that healthcare billing can be complex. That’s why we are committed to helping patients better understand the process, their insurance plan(s), selected benefits and other financial-related information, so they can get back to focusing on what matters most: healing."
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