By Martine G. Brousse
"The Medical Bill Whisperer... and insurance stuff too"
Patient Advocate, Certified Mediator
July 12, 2023
Watch the YouTube video:
"I have received two bills, one from someone I never heard about, for the same service"
I cannot count the number of inquiries I have received, telling me errors were made, even fraud.
I understand the frustrations of patients, and the lack of transparency of a system too uncaring to explain things in advance.
But the answer is yes, you would get 2 bills for the same service, and here is why:
1. First, an essential distinction:
Medical providers are divided in 2 main categories:
"Professional" means "people"
Doctors & specialists (your Primary Care Physician, cardiologist, pediatrician, anesthesiologist, ER Dr, etc)
Hospitalists (who see you while you are in a hospital)
Mental Health Therapists
Other therapists (PT, OT, speech..)
"Facility" means "place"
Hospital (use of the premises and equipment, supplies, Rx, etc)
Imaging Center (for X-rays, MRIs, CT scans etc)
Urgent care clinics
Mental health residential facility
Post-Care facility (Skilled nursing Home etc)
2. Why two bills though?
For certain care, including but not limited to: imaging, pathology, anesthesia, certain labs, surgery, diagnostic and some therapeutic services, there are 2 levels:
the equipment/supplies/machines needed to perform that service
the Dr whose expertise and time are needed to interpret results, and act on them
So, let's say you are having a surgery at a hospital after a visit to the ER:
The facility (hospital) will bill your insurance (and you) for:
using the ER, using their operating room, and for your bed (and potentially terrible food)
using their equipment, supplies and Rx
using their employees (nurses, X-ray technicians, lab technicians etc)
The "professionals" will bill your insurance (and you) for:
Interpreting your scans and tests, reporting on your pathology samples or lab results, and coming to a course of action
Evaluating you in the ER, putting you to sleep (and hopefully waking you up), cutting you open, and monitoring your progress
Two bills from two separate entities for the same "anesthesia" or "surgery" service.
Most "professionals" are NOT employees of facilities where they work. They can, and must, bill for their services separately, and in addition to the "facility" charges.
Another example: You go to get a MRI at an imaging center, and get a second bill from Dr Smith, whom you never met or consulted.
The "facility" will bill for the use of their machine and the time of their technician operating it. But only a MD can read the results: hence the second bill from a Dr who do not need to meet face to face.
In a way, it is a bit like your car mechanic. You get charges for his time and expertise ("Labor" = "professional") as well as for spare parts ("facility")
3. The important part
Where errors or issues arise is when one provider bills a different level of care than the corresponding other.
THE MORE COMPLICATED THE CASE, THE MORE TIME SPENT ON IT, THE HIGHER THE LEVEL OF CARE.
A good common example is in the ER.
The ER Dr may bill level 4 (serious but not life-threatening) while the facility bills level 5 (definitely deploying all measures to save you from an early demise).
The insurance may pay both at the level submitted to them, or reject both until medical records are provided for a review. In the meantime, you might get billed by both providers for the full amount.
What to do?
Contact the provider who billed the highest level and dispute the coding (in writing), based on the other's charges (the EOB from your insurance will reflect them)
File a request for a review, or even a complaint, with the provider who billed the highest level
Contact your insurance to request a review of the higher-coded charge
Contact a Patient Advocate specializing in Coding or Billing. One claim may have been under-coded and therefore it is to your advantage not to bring it to anyone's attention.
It is helpful to remember that when 2 entities are involved in a medical service, it will be logical that both bill separately even if using the same procedure name or code.
As long as those match, you should be OK.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2023
@ the medical bill whisperer 2023