How can I dispute hapital’s predatory billing?

[Anonymous]

I am shocked that your insurance approved you getting those shots at a hospital.

[Anonymous]

Anonymous wrote:Ask for an itemized bill, which they are required by law to provide to you. They should be able to provide you the revenue codes and room and board used to justify a facility bill of that size. Call and tell them you want to see the itemized bill and charges for facility based services. Based on this you can see what exactly composed that 11K charge and then dispute that specifically. The amount they are charging you is equivalent to a one day inpatient stay and extraordinarily high. If they uphold the charge take it to your insurance company as potential fraud, because that charge is completely inappropriate for an outpatient , non-skilled setting with no admission.

They gave me an itemized bill that didn’t break out the facility fee. Would I ask for a superbill or something else?

[Anonymous]

Anonymous wrote:This is bananas. Shouldn't it be done in a dermatologist's office?

This is done by a neurologist for migraine headaches. This is not cosmetic Botox! (NP)

[Anonymous]

Anonymous wrote:

Anonymous wrote:Some people who aren’t fully familiar with medical billing practices are weighing in with uninformed advice here.

Botox is billed as a “procedure,” and procedure charges are high—much more so than a regular doctor’s visit. Also, some physician offices and practices are very aggressive with their billing. They have some latitude about which billing codes to use and how to itemize billing.

Yes, hospital campuses can and usually do charge a facility fee on top of the provider’s fee. Don’t go to physician offices on hospital
campuses if you can avoid it; it’s always more expensive. For the uninitiated, this isn’t booking an OR for a minor procedure or going to the emergency department: Many hospitals have outpatient physician services on their grounds; MedStar Washington Hospital Center and Georgetown among them. Facility fees are poorly regulated and an attempt to make up for some reimbursement rates being lower than the cost of care. Medicare will not pay a facility fee that is not disclosed in advance. You could try arguing that same standard should apply to all patients.

OP should also log on to her insurance’s website. There will be an explanation of benefits for the date of service. If the insurance company has disallowed the facility fee, or if it was never billed through to insurance in the first place, then OP does not owe the co-insurance on the fee. In some cases, your insurer will help you negotiate with the provider, as they hate high fees as much as you do. You can get a representative on the phone and ask for a three-way call with a hospital billing representative.

Hospitals often have an ombudsman. Among other duties, they can help with incorrect charges. While some sort of facilities fee may apply here, this fee is excessive for a 15-minute out-patient procedure in a physician’s
office. If the hospital or hospital system does not have an ombudsman, your state or city may have one. In DC, the attorney general’s office also does a great job of connecting residents to appropriate resources for consumer protection.

OP. You sound extremely knowledgeable. Thanks so much for this helpful advice. I’m aware of facility fees, but this is the first one I’ve had at this order of magnitude. This hospital had a contracts disputevwith BCBS months ago but ended up contracting with them again. As you said, this aggressive billing for facility fees is probably to r\compensate for low reimbursement rates they agreed to.

I will check the EOB soon. From the hospital’s statement, BCBS paid out around $900 total, presumably for the physician fee and medication. They definitely didn't;t cover any major part of the $13,000 facility fee. How would you convince an average BCBS rep get on the phone with the hospital’s billing? I imagine they most would tell me it;s a billing issue and that I should take it up with them.

Also, the hospital did not give me a superbill with codes. Should I ask for that first before i go to insurance?

Thank you again, PP.

My experience is they do it very easily. My problem was not the same as yours, but I call and explain my issues and they are always happy to call billing for me.

I suggest you call first, as your insurance may already have those codes. Tell the insurance rep what you said here, that you don't understand what your benefits are, and how much you should are supposed to be paying. In my experience with BCBS basic, the hospital facility fee is part of the copay, not coinsurance. The insurance rep should consult the handbook to determine if you have to pay coinsurance on facility and if they are allowed to charge you for that.

[Anonymous]

Call your insurance company. If this is a participating provider, they are violating their contract with the insurer.

If they're not a PP, switch to a provider that is.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Some people who aren’t fully familiar with medical billing practices are weighing in with uninformed advice here.

Botox is billed as a “procedure,” and procedure charges are high—much more so than a regular doctor’s visit. Also, some physician offices and practices are very aggressive with their billing. They have some latitude about which billing codes to use and how to itemize billing.

Yes, hospital campuses can and usually do charge a facility fee on top of the provider’s fee. Don’t go to physician offices on hospital
campuses if you can avoid it; it’s always more expensive. For the uninitiated, this isn’t booking an OR for a minor procedure or going to the emergency department: Many hospitals have outpatient physician services on their grounds; MedStar Washington Hospital Center and Georgetown among them. Facility fees are poorly regulated and an attempt to make up for some reimbursement rates being lower than the cost of care. Medicare will not pay a facility fee that is not disclosed in advance. You could try arguing that same standard should apply to all patients.

OP should also log on to her insurance’s website. There will be an explanation of benefits for the date of service. If the insurance company has disallowed the facility fee, or if it was never billed through to insurance in the first place, then OP does not owe the co-insurance on the fee. In some cases, your insurer will help you negotiate with the provider, as they hate high fees as much as you do. You can get a representative on the phone and ask for a three-way call with a hospital billing representative.

Hospitals often have an ombudsman. Among other duties, they can help with incorrect charges. While some sort of facilities fee may apply here, this fee is excessive for a 15-minute out-patient procedure in a physician’s
office. If the hospital or hospital system does not have an ombudsman, your state or city may have one. In DC, the attorney general’s office also does a great job of connecting residents to appropriate resources for consumer protection.

OP. You sound extremely knowledgeable. Thanks so much for this helpful advice. I’m aware of facility fees, but this is the first one I’ve had at this order of magnitude. This hospital had a contracts disputevwith BCBS months ago but ended up contracting with them again. As you said, this aggressive billing for facility fees is probably to r\compensate for low reimbursement rates they agreed to.

I will check the EOB soon. From the hospital’s statement, BCBS paid out around $900 total, presumably for the physician fee and medication. They definitely didn't;t cover any major part of the $13,000 facility fee. How would you convince an average BCBS rep get on the phone with the hospital’s billing? I imagine they most would tell me it;s a billing issue and that I should take it up with them.

Also, the hospital did not give me a superbill with codes. Should I ask for that first before i go to insurance?

Thank you again, PP.

If this is a participating provider, BCBS absolutely will care. The last time I had this issue, the insurer's customer service rep called the provider's billing office with me on the line and politely reminded them of their terms and told them to knock it off, then said, "Ms. Smith is on the line, so can you assure her that she won't be receiving any more bills for this service?" It was delightful TBH.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Some people who aren’t fully familiar with medical billing practices are weighing in with uninformed advice here.

Botox is billed as a “procedure,” and procedure charges are high—much more so than a regular doctor’s visit. Also, some physician offices and practices are very aggressive with their billing. They have some latitude about which billing codes to use and how to itemize billing.

Yes, hospital campuses can and usually do charge a facility fee on top of the provider’s fee. Don’t go to physician offices on hospital
campuses if you can avoid it; it’s always more expensive. For the uninitiated, this isn’t booking an OR for a minor procedure or going to the emergency department: Many hospitals have outpatient physician services on their grounds; MedStar Washington Hospital Center and Georgetown among them. Facility fees are poorly regulated and an attempt to make up for some reimbursement rates being lower than the cost of care. Medicare will not pay a facility fee that is not disclosed in advance. You could try arguing that same standard should apply to all patients.

OP should also log on to her insurance’s website. There will be an explanation of benefits for the date of service. If the insurance company has disallowed the facility fee, or if it was never billed through to insurance in the first place, then OP does not owe the co-insurance on the fee. In some cases, your insurer will help you negotiate with the provider, as they hate high fees as much as you do. You can get a representative on the phone and ask for a three-way call with a hospital billing representative.

Hospitals often have an ombudsman. Among other duties, they can help with incorrect charges. While some sort of facilities fee may apply here, this fee is excessive for a 15-minute out-patient procedure in a physician’s
office. If the hospital or hospital system does not have an ombudsman, your state or city may have one. In DC, the attorney general’s office also does a great job of connecting residents to appropriate resources for consumer protection.

OP. You sound extremely knowledgeable. Thanks so much for this helpful advice. I’m aware of facility fees, but this is the first one I’ve had at this order of magnitude. This hospital had a contracts disputevwith BCBS months ago but ended up contracting with them again. As you said, this aggressive billing for facility fees is probably to r\compensate for low reimbursement rates they agreed to.

I will check the EOB soon. From the hospital’s statement, BCBS paid out around $900 total, presumably for the physician fee and medication. They definitely didn't;t cover any major part of the $13,000 facility fee. How would you convince an average BCBS rep get on the phone with the hospital’s billing? I imagine they most would tell me it;s a billing issue and that I should take it up with them.

Also, the hospital did not give me a superbill with codes. Should I ask for that first before i go to insurance?

Thank you again, PP.

My experience is they do it very easily. My problem was not the same as yours, but I call and explain my issues and they are always happy to call billing for me.

I suggest you call first, as your insurance may already have those codes. Tell the insurance rep what you said here, that you don't understand what your benefits are, and how much you should are supposed to be paying. In my experience with BCBS basic, the hospital facility fee is part of the copay, not coinsurance. The insurance rep should consult the handbook to determine if you have to pay coinsurance on facility and if they are allowed to charge you for that.

Thank you. Per the EOB, the hospital didn’t bill insurance for the facility fee at all . They only billed the $2000 physician fee and medication, which insurance covered their share of.

If they are not billing the facility fee to BCBS, how can they charge me “coinsurance” for the $13,000?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Some people who aren’t fully familiar with medical billing practices are weighing in with uninformed advice here.

Botox is billed as a “procedure,” and procedure charges are high—much more so than a regular doctor’s visit. Also, some physician offices and practices are very aggressive with their billing. They have some latitude about which billing codes to use and how to itemize billing.

Yes, hospital campuses can and usually do charge a facility fee on top of the provider’s fee. Don’t go to physician offices on hospital
campuses if you can avoid it; it’s always more expensive. For the uninitiated, this isn’t booking an OR for a minor procedure or going to the emergency department: Many hospitals have outpatient physician services on their grounds; MedStar Washington Hospital Center and Georgetown among them. Facility fees are poorly regulated and an attempt to make up for some reimbursement rates being lower than the cost of care. Medicare will not pay a facility fee that is not disclosed in advance. You could try arguing that same standard should apply to all patients.

OP should also log on to her insurance’s website. There will be an explanation of benefits for the date of service. If the insurance company has disallowed the facility fee, or if it was never billed through to insurance in the first place, then OP does not owe the co-insurance on the fee. In some cases, your insurer will help you negotiate with the provider, as they hate high fees as much as you do. You can get a representative on the phone and ask for a three-way call with a hospital billing representative.

Hospitals often have an ombudsman. Among other duties, they can help with incorrect charges. While some sort of facilities fee may apply here, this fee is excessive for a 15-minute out-patient procedure in a physician’s
office. If the hospital or hospital system does not have an ombudsman, your state or city may have one. In DC, the attorney general’s office also does a great job of connecting residents to appropriate resources for consumer protection.

OP. You sound extremely knowledgeable. Thanks so much for this helpful advice. I’m aware of facility fees, but this is the first one I’ve had at this order of magnitude. This hospital had a contracts disputevwith BCBS months ago but ended up contracting with them again. As you said, this aggressive billing for facility fees is probably to r\compensate for low reimbursement rates they agreed to.

I will check the EOB soon. From the hospital’s statement, BCBS paid out around $900 total, presumably for the physician fee and medication. They definitely didn't;t cover any major part of the $13,000 facility fee. How would you convince an average BCBS rep get on the phone with the hospital’s billing? I imagine they most would tell me it;s a billing issue and that I should take it up with them.

Also, the hospital did not give me a superbill with codes. Should I ask for that first before i go to insurance?

Thank you again, PP.

My experience is they do it very easily. My problem was not the same as yours, but I call and explain my issues and they are always happy to call billing for me.

I suggest you call first, as your insurance may already have those codes. Tell the insurance rep what you said here, that you don't understand what your benefits are, and how much you should are supposed to be paying. In my experience with BCBS basic, the hospital facility fee is part of the copay, not coinsurance. The insurance rep should consult the handbook to determine if you have to pay coinsurance on facility and if they are allowed to charge you for that.

Thank you. Per the EOB, the hospital didn’t bill insurance for the facility fee at all . They only billed the $2000 physician fee and medication, which insurance covered their share of.

If they are not billing the facility fee to BCBS, how can they charge me “coinsurance” for the $13,000?

Sounds like this is a billing error. If the provider and hospital are in-network, the whole bill, including the facility fee, should be submitted to your insurance. Your insurance will then tell you what you owe on the facility fee.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Some people who aren’t fully familiar with medical billing practices are weighing in with uninformed advice here.

Botox is billed as a “procedure,” and procedure charges are high—much more so than a regular doctor’s visit. Also, some physician offices and practices are very aggressive with their billing. They have some latitude about which billing codes to use and how to itemize billing.

Yes, hospital campuses can and usually do charge a facility fee on top of the provider’s fee. Don’t go to physician offices on hospital
campuses if you can avoid it; it’s always more expensive. For the uninitiated, this isn’t booking an OR for a minor procedure or going to the emergency department: Many hospitals have outpatient physician services on their grounds; MedStar Washington Hospital Center and Georgetown among them. Facility fees are poorly regulated and an attempt to make up for some reimbursement rates being lower than the cost of care. Medicare will not pay a facility fee that is not disclosed in advance. You could try arguing that same standard should apply to all patients.

OP should also log on to her insurance’s website. There will be an explanation of benefits for the date of service. If the insurance company has disallowed the facility fee, or if it was never billed through to insurance in the first place, then OP does not owe the co-insurance on the fee. In some cases, your insurer will help you negotiate with the provider, as they hate high fees as much as you do. You can get a representative on the phone and ask for a three-way call with a hospital billing representative.

Hospitals often have an ombudsman. Among other duties, they can help with incorrect charges. While some sort of facilities fee may apply here, this fee is excessive for a 15-minute out-patient procedure in a physician’s
office. If the hospital or hospital system does not have an ombudsman, your state or city may have one. In DC, the attorney general’s office also does a great job of connecting residents to appropriate resources for consumer protection.

OP. You sound extremely knowledgeable. Thanks so much for this helpful advice. I’m aware of facility fees, but this is the first one I’ve had at this order of magnitude. This hospital had a contracts disputevwith BCBS months ago but ended up contracting with them again. As you said, this aggressive billing for facility fees is probably to r\compensate for low reimbursement rates they agreed to.

I will check the EOB soon. From the hospital’s statement, BCBS paid out around $900 total, presumably for the physician fee and medication. They definitely didn't;t cover any major part of the $13,000 facility fee. How would you convince an average BCBS rep get on the phone with the hospital’s billing? I imagine they most would tell me it;s a billing issue and that I should take it up with them.

Also, the hospital did not give me a superbill with codes. Should I ask for that first before i go to insurance?

Thank you again, PP.

My experience is they do it very easily. My problem was not the same as yours, but I call and explain my issues and they are always happy to call billing for me.

I suggest you call first, as your insurance may already have those codes. Tell the insurance rep what you said here, that you don't understand what your benefits are, and how much you should are supposed to be paying. In my experience with BCBS basic, the hospital facility fee is part of the copay, not coinsurance. The insurance rep should consult the handbook to determine if you have to pay coinsurance on facility and if they are allowed to charge you for that.

Thank you. Per the EOB, the hospital didn’t bill insurance for the facility fee at all . They only billed the $2000 physician fee and medication, which insurance covered their share of.

If they are not billing the facility fee to BCBS, how can they charge me “coinsurance” for the $13,000?

This is a key issue for you to raise. Absolutely call BCBS in the morning. They really are very nice in my experience.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Some people who aren’t fully familiar with medical billing practices are weighing in with uninformed advice here.

Botox is billed as a “procedure,” and procedure charges are high—much more so than a regular doctor’s visit. Also, some physician offices and practices are very aggressive with their billing. They have some latitude about which billing codes to use and how to itemize billing.

Yes, hospital campuses can and usually do charge a facility fee on top of the provider’s fee. Don’t go to physician offices on hospital
campuses if you can avoid it; it’s always more expensive. For the uninitiated, this isn’t booking an OR for a minor procedure or going to the emergency department: Many hospitals have outpatient physician services on their grounds; MedStar Washington Hospital Center and Georgetown among them. Facility fees are poorly regulated and an attempt to make up for some reimbursement rates being lower than the cost of care. Medicare will not pay a facility fee that is not disclosed in advance. You could try arguing that same standard should apply to all patients.

OP should also log on to her insurance’s website. There will be an explanation of benefits for the date of service. If the insurance company has disallowed the facility fee, or if it was never billed through to insurance in the first place, then OP does not owe the co-insurance on the fee. In some cases, your insurer will help you negotiate with the provider, as they hate high fees as much as you do. You can get a representative on the phone and ask for a three-way call with a hospital billing representative.

Hospitals often have an ombudsman. Among other duties, they can help with incorrect charges. While some sort of facilities fee may apply here, this fee is excessive for a 15-minute out-patient procedure in a physician’s
office. If the hospital or hospital system does not have an ombudsman, your state or city may have one. In DC, the attorney general’s office also does a great job of connecting residents to appropriate resources for consumer protection.

OP. You sound extremely knowledgeable. Thanks so much for this helpful advice. I’m aware of facility fees, but this is the first one I’ve had at this order of magnitude. This hospital had a contracts disputevwith BCBS months ago but ended up contracting with them again. As you said, this aggressive billing for facility fees is probably to r\compensate for low reimbursement rates they agreed to.

I will check the EOB soon. From the hospital’s statement, BCBS paid out around $900 total, presumably for the physician fee and medication. They definitely didn't;t cover any major part of the $13,000 facility fee. How would you convince an average BCBS rep get on the phone with the hospital’s billing? I imagine they most would tell me it;s a billing issue and that I should take it up with them.

Also, the hospital did not give me a superbill with codes. Should I ask for that first before i go to insurance?

Thank you again, PP.

My experience is they do it very easily. My problem was not the same as yours, but I call and explain my issues and they are always happy to call billing for me.

I suggest you call first, as your insurance may already have those codes. Tell the insurance rep what you said here, that you don't understand what your benefits are, and how much you should are supposed to be paying. In my experience with BCBS basic, the hospital facility fee is part of the copay, not coinsurance. The insurance rep should consult the handbook to determine if you have to pay coinsurance on facility and if they are allowed to charge you for that.

Thank you. Per the EOB, the hospital didn’t bill insurance for the facility fee at all . They only billed the $2000 physician fee and medication, which insurance covered their share of.

If they are not billing the facility fee to BCBS, how can they charge me “coinsurance” for the $13,000?

Sounds like this is a billing error. If the provider and hospital are in-network, the whole bill, including the facility fee, should be submitted to your insurance. Your insurance will then tell you what you owe on the facility fee.

The hospital and provider are INN per OP. Insirance is never going to pay even a fraction of $13K. I’m guessing the hospital got the prior auth for the $2000 and is now trying their luck for the extra.

[Anonymous]

Anonymous wrote:Why are you going to a hospital for Botox????

This. I recognize it isn't helpful to hear this after the fact, but hospital facility fees are much, much higher than outpatient centers.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Some people who aren’t fully familiar with medical billing practices are weighing in with uninformed advice here.

Botox is billed as a “procedure,” and procedure charges are high—much more so than a regular doctor’s visit. Also, some physician offices and practices are very aggressive with their billing. They have some latitude about which billing codes to use and how to itemize billing.

Yes, hospital campuses can and usually do charge a facility fee on top of the provider’s fee. Don’t go to physician offices on hospital
campuses if you can avoid it; it’s always more expensive. For the uninitiated, this isn’t booking an OR for a minor procedure or going to the emergency department: Many hospitals have outpatient physician services on their grounds; MedStar Washington Hospital Center and Georgetown among them. Facility fees are poorly regulated and an attempt to make up for some reimbursement rates being lower than the cost of care. Medicare will not pay a facility fee that is not disclosed in advance. You could try arguing that same standard should apply to all patients.

OP should also log on to her insurance’s website. There will be an explanation of benefits for the date of service. If the insurance company has disallowed the facility fee, or if it was never billed through to insurance in the first place, then OP does not owe the co-insurance on the fee. In some cases, your insurer will help you negotiate with the provider, as they hate high fees as much as you do. You can get a representative on the phone and ask for a three-way call with a hospital billing representative.

Hospitals often have an ombudsman. Among other duties, they can help with incorrect charges. While some sort of facilities fee may apply here, this fee is excessive for a 15-minute out-patient procedure in a physician’s
office. If the hospital or hospital system does not have an ombudsman, your state or city may have one. In DC, the attorney general’s office also does a great job of connecting residents to appropriate resources for consumer protection.

OP. You sound extremely knowledgeable. Thanks so much for this helpful advice. I’m aware of facility fees, but this is the first one I’ve had at this order of magnitude. This hospital had a contracts disputevwith BCBS months ago but ended up contracting with them again. As you said, this aggressive billing for facility fees is probably to r\compensate for low reimbursement rates they agreed to.

I will check the EOB soon. From the hospital’s statement, BCBS paid out around $900 total, presumably for the physician fee and medication. They definitely didn't;t cover any major part of the $13,000 facility fee. How would you convince an average BCBS rep get on the phone with the hospital’s billing? I imagine they most would tell me it;s a billing issue and that I should take it up with them.

Also, the hospital did not give me a superbill with codes. Should I ask for that first before i go to insurance?

Thank you again, PP.

My experience is they do it very easily. My problem was not the same as yours, but I call and explain my issues and they are always happy to call billing for me.

I suggest you call first, as your insurance may already have those codes. Tell the insurance rep what you said here, that you don't understand what your benefits are, and how much you should are supposed to be paying. In my experience with BCBS basic, the hospital facility fee is part of the copay, not coinsurance. The insurance rep should consult the handbook to determine if you have to pay coinsurance on facility and if they are allowed to charge you for that.

Thank you. Per the EOB, the hospital didn’t bill insurance for the facility fee at all . They only billed the $2000 physician fee and medication, which insurance covered their share of.

If they are not billing the facility fee to BCBS, how can they charge me “coinsurance” for the $13,000?

That doesn't sound right. Hospitals aren't going to allow procedures if they can't bill for a facility fee. There are cases where insurers won't reimburse facility fees, but hospitals aren't a typical case of that.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Why are you going to a hospital for Botox????

This. I recognize it isn't helpful to hear this after the fact, but hospital facility fees are much, much higher than outpatient centers.

OP. I have tried a number physicians who offer this service. The level of pain relief depends a great deal on how well the botox is placed. This is the best provider in the area. I will now have to drive an hour and take my chances.

As for cost, many non-hospital providers are OON for this service. I’ve had this done in hospital settings in other areas. This is the first facility fee I have ever seen that’s anywhere near this level.

[Anonymous]

Tell the provider to submit the claim for facility fee to the insurer. I don’t have BCBS, but I’m currently in active treatment for cancer and many of the providers are hospital-based physicians, and even regular “consult” type appointments have an attached facility fee that is submitted to my insurance and processed along with the main claim.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Why are you going to a hospital for Botox????

This. I recognize it isn't helpful to hear this after the fact, but hospital facility fees are much, much higher than outpatient centers.

OP. I have tried a number physicians who offer this service. The level of pain relief depends a great deal on how well the botox is placed. This is the best provider in the area. I will now have to drive an hour and take my chances.

As for cost, many non-hospital providers are OON for this service. I’ve had this done in hospital settings in other areas. This is the first facility fee I have ever seen that’s anywhere near this level.

I'm curious- were these encounters coded the same way but the providers?

My guess, though, is that you may be hitting a combination of a higher-than-historically-normal facility fee with insurance plan changes to not cover facility fees at hospitals for services that could be done in ambulatory care center. They probably had you sign a notice that warned you, in very vague terms, that you could be on the hook for the facility fee if the insurance company wouldn't pay it. This comes up with other kinds of procedures, too, like colonoscopies.