Don’t Pay for That Service: You Might Not Owe Anything! 

Challenge: A patient had knee surgery at an ambulatory surgery center (ASC), a surgery center outside of the hospital. When that happens, patients generally receive multiple bills from different entities - you might receive a bill from the surgeon (the doctor), a bill for the surgery center (a facility fee), a fee for equipment (maybe crutches), and a fee for the anesthesiologist. In this case, bills for the surgeon, facility, and crutches arrived and matched. But the bill from the anesthesiologist was…wonky. They billed $3,500 for a 30-minute surgery!  

Issue: After her surgery, the patient was not sure why she was being charged and asked to pay so much for anesthesiology services. Aside from the fact that the charge was enormous (nearly $3,500), doctors never get paid what they charge. So, while the anesthesiologist continued to bill the patient multiple times for $3,500, we noticed that the anesthesiologist had not yet billed the patient’s insurance company. The anesthesiologist then sent the patient to collections. Most people would’ve paid. That would’ve been wrong.

Process: We worked with the patient to get to the bottom of the issue. We examined the bill, informed her she was right not to pay, and called the collection agency. We noted that the claim had not been filed with insurance company and we provided the patient’s insurance information. If the claim had been filed with insurance the patient might’ve owed $500 or so. We then called her insurance company to find out about “timely filing.” The claim had to be filed within 15 months of the surgery.

Outcome: Short version: victory! The collection agency, and the practice, never filed the claim with the insurance company. After 15 months the claim “aged out” for missing timely filing. Not only did the patient not owe $3,500, she owed NOTHING.  

The moral of the story: Know your rights and try to understand the process. It could save you hundreds, maybe thousands, of dollars!!

Fight the Good Fight – Appealing a Claim - And Winning

Challenge: A patient had a Risk of Ovarian Malignancy Algorithm (ROMA) diagnostic test performed. This test was ordered by her physician to help assess the likelihood that an ovarian or adnexal mass (a mass near the ovaries) was cancerous. The physician thought the test was medically necessary.

Issue: The insurance company denied the ROMA study as “not medically necessary.” Since the insurance company denied the claim the patient paid $575 out of pocket. The test was necessary per the physician.

Process: We worked with the patient to get to the bottom of the issue. We appealed the denial; the claim was denied yet again (even though we submitted the requested office notes and information substantiating the claim). The BIG insurance company gave us the run-around. Our history in healthcare helped us fight through the noise.

We requested an outside appeal providing, yet again, the physician’s notes indicating the medical necessity of the requested test. 

Outcome: Short version: victory! After a process of 20 months, the denial was reversed and the patient was reimbursed the $575 she had paid out of pocket for the necessary test.

The moral of the story: When your doctor thinks a medical procedure is legitimate and beneficial, fight your insurance company for appropriate payment of services. As this case points out, it could be worth your time!