CDA Press Consumer Guy: Medical billing code errors really can make you sick

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Now that we all have health insurance and everything is paid for, we don’t need to pay attention to our hospital/doctors/or other medical bills and charges. Right? WRONG!

Most people have deductibles, the amount you pay. Sometimes (often), insurance companies don’t pay what we thought they were going to pay. Here’s why.

Medical insurance, private and government insurances rely on a system known as ICD coding (International Classification of Disease). The current versions are ICD-9 and ICD-10 coding. It’s irritating to visit a doctor, pay your deductible and a week or two later get another bill from your doctor in the mail asking you to pay an additional amount. Often the cause of this is that the medical billing clerk has entered the wrong code.

You should insist that the medical provider give you the ICD code numbers and the specific name of the condition and procedure you and/or your insurance provider is being billed for, usually on your statement. If the code entry clerk made a mistake, it could cost you big bucks.

I had a complaint from a man who said his insurance company would not pay for the procedure he had recently undergone at a local hospital. I did some investigating on his behalf with the hospital and found his procedure was coded as a 68-49, an “unspecified total abdominal hysterectomy.” No wonder the insurance company refused to pay the bill. Unfortunately, the hospital kept billing the man and finally threatened to turn him over to collections. Once the correct ICD code for the correct procedure was entered and submitted to insurance, the bill was paid in accordance with his policy coverage.

FUNNY NOTE: Two of the many new ICD9/10 codes are: ICD 10 – W61.01 Bitten by a Parrot, and ICD 9 V97.33XD Sucked into a Jet Engine (Subsequent Occurrence). Subsequent occurrence???

In addition to being “The CDA Press Consumer Guy” and an associate real estate broker, I am also an independent insurance adjuster, licensed in Idaho (license No. 105830). I CAN, with your written permission, legally talk to your insurance company or healthcare provider. One important thing to remember: Keep all your medical bills and insurance company mailings together in one place. It’s very hard to help you if I don’t have documentation.

LESSON: Check your health care bills and statements carefully.

Most people believe that the insurance adjuster employed by your company is on your side. Not necessarily so. In my opinion, the primary duty of an insurance company’s adjuster is to limit the insurance company’s liability. Their second duty is to serve the insured — you. Especially if you’re involved in a situation where you may have liability (fault), like an automobile accident, do not, under any circumstance, give statements or talk with an insurance adjuster other than your own. Even then, be careful; don’t admit fault even if your adjuster tries to get you to. If you didn’t do anything wrong don’t admit to anything. Adjusters are partially paid on their ability to clear cases quickly and keep claims costs to a minimum. Remember that.

Another very important way to save money is to shop and compare prices. The cost of procedures and medical equipment are pretty much the same. Right? WRONG! It depends largely on who insures you and where you go.

Insurance companies negotiate with various providers for different prices. Recently a consumer purchased a wheelchair online for $150, fully assembled including free shipping. While shopping at a local medical equipment store for a cane, the consumer saw the exact same wheelchair for sale, except there was no price tag on the chair. When asked about the price, the clerk, instead of telling the consumer the cost of the chair, asked what kind of insurance the consumer was covered by. The consumer replied that she had no insurance but just wanted to know the “cash price.”

The store clerk had a difficult time finding a non-insurance price. Finally she appeared and announced that the cash price would be $1,150 plus a charge for shipping and assembly. That’s approximately an 800 percent increase over the online price! Another consumer found that by “price shopping” for a colonoscopy, she was able to cut the price by 50 percent. Both doctors had the same qualifications, degrees and consumer rating and worked at the same hospitals.

LESSON: Shop around to the extent your health care insurance allows it.

QUICK KUDO: Spectrum has been working hard to clear subscriber complaints. Hat tip to the people in the local office and the regional executive in Denver. Keep up the good work.

QUICK TIP: As the weather warms, the door-to-door sales people come out — kinda like mosquitos. If you want a classy looking CDA Press Consumer Guy “No Soliciting” sign, please email me at If I get enough requests I will have some made up. In any event, NEVER open the door if you don’t know who’s on the other side. Most home break-ins occur between the hours of 10 a.m. and 3 p.m.! Also, anyone selling anything door-to-door requires a license from the city. When in doubt — call the police.

The blog is coming along nicely. If you’d like to take a look go to

I have many more interesting cases that I’m working on as The CDA Press Consumer Guy. Call me at (208) 449-7222, email me at CDAPressConsumerGuy or fax me at (866) 362-9266. Also include your full name and a phone number. I am available to speak about consumerism to schools, and local and civic groups.

• • •

Bill Brooks is the CDA Press Consumer Guy. He is an active associate real estate broker for Tomlinson-Sotheby’s International Realty in Coeur d’Alene.

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