Medical bill (incorrect code used), Doctor's office refuses to fix

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Aug 15, 2017
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Hi all,

I have a medical bill I'm really hoping to get advice on how to proceed on. I took my newborn daughter in for her first week well child visit, due to the hospital's policy that all newborns need to be seen within 48 hours of discharge by a pediatrician. I was already worried about high medical bills relating to her birth and had no wish to incur even more out of pocket expenses. However, the nurse at the hospital told me well-child visits are considered preventative care and are covered 100% by health insurance (no co-pays required).

Reassured, I took her in and the pediatrician did a standard well child visit. She did a physical exam, measured her weight, length, head circumference, checked for newborn jaundice, asked about feeding, pooping, number of diaper changes..etc. The pediatrician then asked me to return the next day to check her jaundice levels again. And for the following day after that, in total for 3 pediatrician visits. Each visit the pediatrician repeated the same steps (weight, length, head circ, physical exam...etc.)

When my EOB arrived a few weeks later, I was surprised to see all 3 visits were coded as $40 office visits instead of preventative well child visits. I called my health insurance and the representative told me an office visit should be coded for diagnostic purposes, for instance if my newborn had an upset stomach, rash, or fever. (My daughter was not sick, so I'm confused why they were billed as office visits.)

I've since e-mailed the pediatrician's office asking them to correct the billing code, but the billing manager would not discuss the matter through e-mail, and when I called she insisted the visits were correctly coded as office visits.

Is there anything I can do to get this fixed?

(I've since discovered, the founder of the pediatric clinic was found guilty of health care fraud for accepting $200,000 in bribes in a test-referrals scheme.)
 

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#2
What does your insurance plan cover? A nurse does not know your plan and can not speak on what is covered.

An article on why wellness visit may not be covered:

Reason 1: Your child's insurance plan is not ACA-compliant.

  • While new group health plans and exchange plans are required to cover all parts of the well child visit with no cost sharing, many health insurance plans are exempt from the ACA and, as a result, this requirement. These include existing unchanged health plans from before the ACA became law ("grandfathered" plans), federal employee plans, government plans like Tricare or ChampVA, ERISA-based self-insured plans, and membership plans like faith-based cost-sharing services.
https://www.healthychildren.org/Eng...-Receive-a-Bill-After-a-Well-Child-Visit.aspx

All you have attached are recommendations that say nothing about your plan and coverage.
 

Neil Maley

Moderator
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Advocate
Dec 27, 2014
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#3
I have to agree with Christina. Was this a nurse at the hospital who told you these visits would be covered? If so, she doesn’t work for your doctor and doesn’t know what your insurance will and won’t cover.

Your insurance company would be the one who should guide you and they should speak to the doctors office about coding a bill properly.
 
Feb 21, 2018
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You mention that jaundice levels were checked - this could be the reason they did not code the visits as 'well child'. When my daughter was born her jaundice was borderline high, and I was told that I needed to have her checked three days after getting home and sooner if her coloring didn't improve. They still check everything they would at a normal visit, but the jaundice is the reason for the visit. (I did have to return...twice).

Was blood drawn at these visits? That might be the telltale sign that the visit was for jaundice. They don't routinely draw blood at a well child visit.
 
Aug 15, 2017
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Christina & Neil,

I had immediately called my health insurance, after receiving the bill and asked if well child visits were subject to co-pay, and the representative said no.

My plan states NO COPAY: Allergy Immunotherapy, Chemotherapy, Hemodialysis, Prenatal Care, Radiation Therapy, Well Child Care.

My health insurance representative basically said all I had to do, was get the pediatrician's office to resubmit the 3 claims as preventative well child visits. Unfortunately, the representative couldn't change the billing code on her end.

But, the pediatician's office isn't willing to correct the billing codes as well child visits.

It seems the pediatrician's office can collect more money from the office visits co-pays, instead of the negotiated rate well child visits from insurance.

I would have had no issue paying for office visits, if my newborn had been genuinely sick (fever, rash, upset stomach). But, to be charged when she was healthy is very distressing.
 
Dec 19, 2014
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#6
Hi all,

I have a medical bill I'm really hoping to get advice on how to proceed on. I took my newborn daughter in for her first week well child visit, due to the hospital's policy that all newborns need to be seen within 48 hours of discharge by a pediatrician. I was already worried about high medical bills relating to her birth and had no wish to incur even more out of pocket expenses. However, the nurse at the hospital told me well-child visits are considered preventative care and are covered 100% by health insurance (no co-pays required).

Reassured, I took her in and the pediatrician did a standard well child visit. She did a physical exam, measured her weight, length, head circumference, checked for newborn jaundice, asked about feeding, pooping, number of diaper changes..etc. The pediatrician then asked me to return the next day to check her jaundice levels again. And for the following day after that, in total for 3 pediatrician visits. Each visit the pediatrician repeated the same steps (weight, length, head circ, physical exam...etc.)

When my EOB arrived a few weeks later, I was surprised to see all 3 visits were coded as $40 office visits instead of preventative well child visits. I called my health insurance and the representative told me an office visit should be coded for diagnostic purposes, for instance if my newborn had an upset stomach, rash, or fever. (My daughter was not sick, so I'm confused why they were billed as office visits.)

I've since e-mailed the pediatrician's office asking them to correct the billing code, but the billing manager would not discuss the matter through e-mail, and when I called she insisted the visits were correctly coded as office visits.

Is there anything I can do to get this fixed?

(I've since discovered, the founder of the pediatric clinic was found guilty of health care fraud for accepting $200,000 in bribes in a test-referrals scheme.)
First of all congratulations on your newborn!
Sadly, insurance, coding and billing is a complicated matter and there are many rules that have to be followed.

1) A well child visit. is just that. A well child visit. If there are ANY issues that are addressed (ie child has a cough, child has a rash, child has jaundice), then the issues that are addressed become an office visit (ie EM code)
2) "the nurse at the hospital told me well-child visits are considered preventitive care and are covered 100% by health insurance" - Without looking at the terms and conditions of your insurance plan, that may or may not be true. While it is true in many cases, there are thousands of insurance plans, and every plan is different.
3) "the hospital's policy that all newborns need to be seen within 48 hours of discharge by a pediatrician" - No hospital would have such a policy. The recommendation for recheck is made by the provider who sees your child. If there is an issue that is identified during the stay at the newborn nursery, the provider will recommend the time frame

You will need to review (or have the provider's notes reviewed by a coder) to determine whether the visits were a well child visit or not. There is too much missing information at this time to determine. Without reviewing the medical record, I'm just speculating, but based on your post, it seems the recommended peds visit was because your baby was jaundiced.... and if that were the case, then the visits are correctly coded as office visits. Sick does not mean physically sick, "sick" as defined in the medical world means addressing any abnormalities. Performing weight, length, head circumference, etc is routine for ALL newborn visits, whether it is a well child visit or not.

If you wish to pursue this further here are the steps I would take
1) Arrange a sit down meeting with the practice manager or billing manager in the office.
2) If the pediatrician office is hospital based, call and arrange a meeting with the billing department at the hospital.
3) If the above does not yield a satisfactory result or explanation, then call your insurance company and have them review the charges and codes. Trust me, insurance companies would love the opportunity to prove that a provider's office is incorrectly coding visits

As a side note... well child care visits are typically defined at specific intervals, and you are only allowed 1 visit at such interval.

Finally, if you are unsatisfied with the pediatricians office, you always have the option of changing pediatricians.

Good luck!
 
Aug 15, 2017
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#7
@msmayor I had the same thought so I researched what is typically done in a first week well child visit and a jaundice check is one of the first things they check for. (Since as you know it's very common in babies).

No blood was drawn, the jaundice test was done through a skin device.
 

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#8
Hi Chris,

Thanks for the congratulations. Sorry for any delayed replies. Juggling said newborn at the moment.

Sorry if it wasn't clear, my daughter didn't have jaundice, this was all just checks to monitor her jaundice levels to prevent full blown jaundice.

I really wish at the moment the hospital didn't have the 48 hour policy. I didn't even have a pediatrician picked out yet (baby was born 3 weeks early).

Since, there was no issues in the hospital. It didn't even cross my mind to schedule a pediatrician visit. But, the nurses insisted. It's even on the hospital website.

I will definitely follow your advice to review the provider's notes and codes. Hopefully, the charges can be proven as a preventative well child visit.

I just realized, well if the doctor thought my child was sick (cough, rash, full blown jaundice). And the pediatrician's office billed it that way. Shouldn't the lack of a prescription from the doctor prove she wasn't?
 

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#9

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Dec 19, 2014
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#10
Hi Chris,

Thanks for the congratulations. Sorry for any delayed replies. Juggling said newborn at the moment.

Sorry if it wasn't clear, my daughter didn't have jaundice, this was all just checks to monitor her jaundice levels to prevent full blown jaundice.

I really wish at the moment the hospital didn't have the 48 hour policy. I didn't even have a pediatrician picked out yet (baby was born 3 weeks early).

Since, there was no issues in the hospital. It didn't even cross my mind to schedule a pediatrician visit. But, the nurses insisted. It's even on the hospital website.

I will definitely follow your advice to review the provider's notes and codes. Hopefully, the charges can be proven as a preventative well child visit.

I just realized, well if the doctor thought my child was sick (cough, rash, full blown jaundice). And the pediatrician's office billed it that way. Shouldn't the lack of a prescription from the doctor prove she wasn't?

Some information to help you navigate the perils of the health care system.

A well visit is very defined. Generally they are at specific intervals as recommended by AAP (American Academy of Pediatrics). However, keep in mind that not all insurance plans follow the AAP guidelines. That is the reason why you need to contact your insurance company to find out exactly what they cover in terms of well visits.

A well visit only addresses health maintenance and prevention. It does not and cannot address any acute problems.

Ironically, a well visit actually pays more than a "sick" visit, but nearly all insurances will pay for only 1 well visit per interval. So, if your child was seen 3 times in the first week, by definition, 2 of the subsequent visits are not well visits per se.

A common scenario is a patient will go in for a well visit, and the say, oh by the way, my child has ear pain. The ear pain is a SEPARATE visit, and is not part of the well visit. Proper coding would dictate that you are billed for the well visit AND the office visit. Also, the well visit has it's own diagnostic codes that are associated with it, and certain diagnostic codes cannot be linked to the well visit. In the agreement with the insurance company, proper coding is required. Overcharging is insurance fraud, but so is undercoding. So, a provider CANNOT waive a co-pay, charging a well visit when it was not, billing a lower level code to help the patient, etc.

When you review your charges.... what are the ICD10 codes used? That will provide insight into the billing issue. It will also tell you what the provider addressed in the office visit. The charges and the ICD10 codes need to be supported by the documentation, hence, having a coding expert review the charges and the notes will give you the information you need.

Is your pediatrician office independent (stand alone private practice) or is it part of a group? or part of a hospital? If the practice is part of a group or hospital, I'm going to say that 99.9% probability that the charges are done correctly. That is because group practices and hospital practices have a professional coder that audits because they want to be in compliance.

I will re-iterate, the hospital CANNOT have a policy that all discharges be seen within 48 hours. A hospital is not a clinician. The recommendation was made by a provider who saw your child in the newborn nursery. Since your child was 3 weeks premature, the recommendation for a check in 3 days was appropriate, because your child is high risk for jaundice and other complications.
 
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#11
From the Kaiser website, "In healthy babies, some jaundice almost always appears by 2 to 4 days. It usually gets better or goes away on its own within a week or two without causing problems."

I truly wish I was given this information ahead of time. I wouldn't have brought my newborn in for 3 consecutive visits.

https://thrive.kaiserpermanente.org.../18/2015/11/Newborn-Jaundice_tcm28-199890.pdf
Since your child was PREMATURE, she is not by definition a "healthy" baby. At the end of the day, the provider was concerned enough to monitor your child for 3 days. Again, without reviewing the medical records, that seems to infer that there was a medical issue.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
19,717
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www.promalvacations.com
#12
I think Chris in NC gave great advice. You should request a visit with the pediatrician’s office and meet with them to discuss exactly what type of visits you had.

Not having a pediatrician visit the baby in the hospital seems to be where this problem lies and the advice they gave you. I’m quite surprised if she was premature that they didn’t suggest a pediatrician in the hospital for you that you could have spoken to and arranged a visit with.

Please contact the doctors office and arrange a meeting with the manager ir the doctor to understand why the visits were coded as they were.
 
Likes: VoR61
Aug 15, 2017
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@Chris I'll be calling my health insurance for the ICD10 codes today. Would you have any time to help me decipher the codes? I would really appreciate it.

The pediatrician's office is a stand alone private practice. We wish we weren't pressed by the nurses to schedule an appointment right away. The nurses insisted they needed to know the appointment date and pediatrician name to forward my newborn's medical records.

While my daughter was born early, the hospital staff said she was fully developed at 37 weeks, 6 pounds was an average weight, hearing and vision was fine, newborn screening test was negative). There was no urgent reason to see the pediatrician in the first week. It was just recommended for all babies.
 

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#14
@Neil & Chris

I think there's been an misunderstanding. While my newborn was early at 37 weeks instead of the full 40 weeks. She wouldn't be considered premature.

A Google search shows "at 37 weeks pregnancy is coinside red full-term". Per the attachment.
 

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Aug 15, 2017
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#15
I have no wish to offend anyone giving me advice, in fact I am very thankful for the suggestions given. Just explaining how unnecessary excess medical bills is a huge concern. Given the cost involved already due to her birth.

Thanks again Chris for suggesting I review the ICD10 codes.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
19,717
18,384
113
New York
www.promalvacations.com
#16
No offense taken. It seems the hospital pushed you to make a quick decision and there is a disconnect between what the hospital told you and what the doctors office told you.

I’m not sure how else you can determine what is
or isn’t the correct billing without speaking to someone at the doctors office in person.
 
Likes: JMLamb
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#17
Because billing is in most cases the most complicated and exacting procedure in medicine, miscodes happen a lot and can have a major effect on what you pay. Your insurance company should be able to help out.
 
Jan 6, 2015
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For reference purposes, you can typically find the definition of a CPT code in your browser by typing "CPT code" followed by the number. One or more sites will display it. We use this method frequently . . .
 
Aug 6, 2019
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I’m a nurse. You may be able to ask that the first visit be coded as a well child, but the other 2 do not sound like well child visits. It sounds like they were concerned about your daughter’s bilirubin levels (which is more common in premature infants). The doctor should have explained that to you better, because 3 daily well child visits in a row is not normal. I’m sorry they didn’t explain what was going on better to you.
 
Dec 19, 2014
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@Chris I'll be calling my health insurance for the ICD10 codes today. Would you have any time to help me decipher the codes? I would really appreciate it.

The pediatrician's office is a stand alone private practice. We wish we weren't pressed by the nurses to schedule an appointment right away. The nurses insisted they needed to know the appointment date and pediatrician name to forward my newborn's medical records.

While my daughter was born early, the hospital staff said she was fully developed at 37 weeks, 6 pounds was an average weight, hearing and vision was fine, newborn screening test was negative). There was no urgent reason to see the pediatrician in the first week. It was just recommended for all babies.
@Discrave
Unfortunately, we are advocates here, and cannot offer any professional advice (ie chart review, interpretation of codes, etc).
There are plenty of resources on the internet that can help you decipher CPT codes (billing codes) and ICD-10 codes (diagnosis codes).

I'm truly sorry to hear about your situation. At the end of the day, it seems the underlying issue is a lack of clear communication and/or explanation about the services you are being provided and the financial responsibilities that you may incur from utilizing medical services.

I will reiterate, the next step is to sit down with a face to face meeting with the office or billing manager at the practice, and have them explain the billing process. If that does not resolve the issue, then contact your insurance company. There is just too much missing information, that makes it prohibitive for anyone on an internet forum to be able to give you any specific advice.