Blondie and the (Medical Coding and Billing Error) Beast: Part 1
When Maria spoke to the collections agency about the latest bill she’d received for her daughter’s surgery, the woman on the other end of the phone was encouraging:
You only owe $10,000. It WAS $44,000. You should be happy!
Only $10,000. For a surgery that should not have cost Maria’s family a dime. And Maria was supposed to contritely accept this, be grateful that the bill was “reduced”, whip out her checkbook, and sign away her daughter’s college tuition savings.
Not on my watch.
19 months after Blondie’s injury, 8 months after the surgery that was recommended by two orthopedic specialists to fix the labrum tear and pincer impingement that had not responded to 12 months of physical therapy, Maria’s family is facing their final opportunity to have the primary and secondary insurance pay their portion of the total treatment costs: the external review. And I’m helping them pull together the appeal.
Maria’s daughter, Blondie, was injured on school property during a school-sanctioned athletic event in January of 2015. As parents, we are all told that our children are “covered” by the school’s insurance when our children are participating in official extracurricular programs. What isn’t emphasized, and may not be immediately apparent, is that the school’s insurance is last in line to pay if there is a “coordination of benefits” scenario — meaning, if the child is covered by any other kind of health insurance at the time of the incident, the school’s policy does not pay until and unless that other insurance is exhausted.
And if the primary insurer denies claim payment, the secondary insurer — the school — doesn’t pay, at all, and the family is left to care for an injured child and single-handedly shoulder the medical costs associated with treatment. Which is what is happening to Maria, for a case now spanning 19 months, 6 physicians’ practices, 4 specialties, 1 hospital, 2 federally-mandated billing code standards, and 3 insurers.
I’ll be honest. I expected to review the trail of records and come away angry with the insurer. I expected to rail against the secretive and purposefully vague rules defining “medical necessity”. I expected for the appeal to question the results of the insurer’s black-box medical review board process. It would have been much cleaner than what we did find.
What we discovered in the first 5 hours of digging through a mountain of medical records, bills, and referral letters: 4 of the 6 physician practices involved in the care delivery and coordination for this single injury made clerical errors in their medical coding and/or billing that impacted each referral, subsequent coding and billing, and ultimately, the insurer’s authorization to pay the claims.
It all started with a medical coder recording the injury in the wrong body part. The official diagnosis was coded in ICD-9 as an 840.8, which is a shoulder sprain/strain/tear (first visit). The description of that code that appeared on the encounter record provided to the patient: “Labrum tear.”
The MRI report showed a hip labrum tear, and the first orthopedic specialist’s practice noted the injury correctly in the “Plan of Care” long-form text section of the encounter document — but, somehow, the diagnosis and “Problems” sections, which include ICD and SNOMED codified entries, indicated a shoulder labrum tear and related symptoms. The wrong body part. Treatment began, addressing the hip injury — and never once touching this phantom shoulder problem. With each clinical encounter, the EHR was surely consulted, and the phantom shoulder problems should have been recognized as erroneous — as well as the fact that the hip problem was not identified. Yet, this error wasn’t caught by the medical assistant or physician during several subsequent encounters — and it was propagated to each new referral.
Time passed, and the wheels of the business of healthcare kept turning. The family’s employer contracted with a new insurance company, which changed the medical necessity guidelines to authorize procedures, as well as changing the specialist providers available in-network. The healthcare industry’s billing coding standards changed from ICD-9 to ICD-10. Blondie’s injury did not respond to PT, and her condition deteriorated. Maria sought alternatives.
When the second orthopedic specialist transcribed the medical records from the first, they did not include the shoulder labrum tear codified entries — but they did import the original MRI results. And they treated the hip, referencing the treatment (and the tear) in notes and referral letters. After exhausting the viable non-invasive options, the orthopedist recommended surgery — and the recommendation was confirmed by a second specialist at a different practice.
At the pre-op appointment, Maria and her daughter were given the usual instructions and walk-through of the procedure, the road to recovery, and the risks. Those risks did not include the possibility that insurance may not pay for the procedure — or any subsequent post-op treatment. The office manager assured Maria that they were “good to go” with her insurance coverage for the surgery. That means an authorization should have been approved.
It wasn’t. So, months after the surgery, the bills began to pile up — and some providers refused to continue care until the claims issue had been resolved.
But in an industry where experts estimate anywhere between 7–32% of claims will be denied, and many of those denials result in the healthcare provider selling the debt to a debt-buyer or collections agency — thus absolving themselves of responsibility for resolving the problem with the insurer — the likelihood that the providers involved would have the time or intestinal fortitude to backtrack through the muck to find and fix the problem is practically nil.
What’s a family to do once their providers have literally written them off?
Stay tuned as they fight to tame the beast.
