How can I dispute hapital’s predatory billing?

[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.

[Anonymous]

Anonymous wrote:People so often try to deal with the biller in their panic.
Let your insurance company tell them they are violating their contract. Call them.

Typical bill for me:
Doctor: $500
Hospital fee:$2000
I owe: $20

This. At least to start. Make sure you've been billed correctly and that your insurance has processed it correctly. If you straighten that out and you still owe then I'd start looking at the No Surprises Act. You should have been advised of this fee.

One thing I also have to say - people FREAK OUT over something going to collections. I get it, but you still have rights, even if your bill is sent to collections. Look up the Fair Debt Collection Act and the Fair Credit Reporting Act. Both of those have provisions which allow you to advise the biller that you dispute the bill and they essentially have to stop moving forward with collections until it's sorted out.

And while I'm not recommending it, you can also let it go to collections if everything else fails and force negotiation if you have to. I have excellent credit and would not blink twice in telling the hospital to go screw themselves and note the dispute in my credit report.

[Anonymous]

Anonymous wrote:

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)

That isn't itemized then. Ask them for itemized charges. Each line of the bill will have a description of the service and the corresponding charge.

[Anonymous]

OP. Go on reddit and search for step by step instructions on how to handle the fee. If you can't find anything there, post your OP there and see what posters recommend. I have had great luck on reddit with posters having almost identical customer service/billing issues and what they did to resolve it.

[Anonymous]

My DH sees a specialist at the University of MD, and they are constantly trying to charge a facility fee for office visits (nowhere near the amount you quoted though). Each time he has to call the insurance company and the fee has been waived each time. He has BCBS federal. Definitely speak with a rep from your insurance. Good luck

[Anonymous]

There have been previous threads also; maybe you will find something helpful:

https://www.dcurbanmom.com/jforum/posts/list/1001904.page