In the decade since completing medical school, my family has been sent to collections three times for medical billing. The first was after starting a new job and the bill for a requested add-on service during my employee health onboarding visit was sent to my old address. My new employer could not track me down but the collections agency did so quickly. The second occurred during residency as the aftermath from my stories of gratitude excerpt. The health care system my son went to for emergency care had a separate billing department for provider billing and ambulance billing. A perfect storm happened in my insurance group number changing at the start of 2020, one billing department being denied for submitting their claim after the new year, and the COVID pandemic sending many nonessential workers to work from home. Despite weeks of using my off days attempting to connect with the “correct” billing department through calls, voicemails, and emails, our bill was, again, ultimately sent to collections. My last recourse for this incident involved figuring out the syntax of the hospital system’s email addresses and emailing the CEO. He replied within an hour, having cc’d the CFO to investigate the issue, and the billing was resolved by the end of the week.
Both of these events were, in my mind, understandable mistakes given the circumstances. However, the incidents also highlighted to me, as a clinician-in-training, the state of the system in which we work — bill first and ask questions later seems to be the modus operandi. As a single male who only periodically needed a health care visit, I found it easy to keep track of my medical bills. As my family grew and the number of claims being made against my insurance increased, I’ve found it exponentially more difficult to keep track of what we actually owe. Sometimes we receive two to three bills of differing amounts for the same claim before an explanation of benefits (EOB) is even registered. Good luck reconciling the 20-digit claim number against the 12-digit account number, date of service versus date of claim, and/or any other alphanumerical scramble thrown into the mix.
My first thought every time a wave of new bills and EOBs hits the mailbox is that my insurance should be the middleman in navigating all of my family’s medical billing. From there I could simply pay or dispute through them. After all, my insurer probably doesn’t have to play one-way phone tag with a hospital’s billing department when the hospital is trying to collect on a bill. However, I am quickly reminded of my transition to fellowship when, due to what I assume was a clerical error, my insurer sent over 20 separate envelopes each containing copies of insurance cards from both the old and new plans. “Do I really want this company holding MORE responsibility over my medical billing?” Probably not! I also wonder if consistently coupling the billing and EOBs would lead to less confusion. Maybe some insurers provide EOBs in this fashion, but mine does not currently. Doing so, however, would certainly ease the process of determining if a claim has been appropriately submitted.
As clinicians, I think it’s not uncommon to feel the urge to bury our heads in the sand, refer patients to the nebulous billing department, and “just focus on practicing medicine.” Maybe I am late to the game, but my third run-in with collections made me rethink my mindset in this area with regards to the patients I treat. Long story short, my wife went to a New York City urgent care chain for an in-network visit and lab work, which was covered under our plan. A second bill came months later and the associated EOB was denied as “out-of-network” because the urgent care billed a follow-up phone call to discuss the (very normal) lab work as a “99213 – Level III established patient.” They also submitted the bill under a different tax EIN, which was out-of-network for my insurance. After much back and forth with the billing department and our insurer, we were able to resolve the situation. My guess is a large number of Manhattanites would have just paid the $180 bill. I’ll never know for sure if this billing mishap was intentional, but, either way, I’m pretty certain the clinician that provided the billed services was unaware of the months-long battle we endured after a three-minute phone call.
My takeaway from this scenario is that we, as clinicians, need to be cognizant and vigilant about the billing practices of those billing on our behalf. Appropriate coding is important so that we get appropriately paid for services provided, patients don’t get overbilled, and to facilitate data integrity, which bears important implications in research. On the other hand, the world of insurance and billing is constantly changing in ways most clinicians cannot navigate alone. That said, I believe clinicians can most effectively tread these waters by surrounding themselves with knowledgeable and effective staff who share a desire for accurate billing and understand the ever-changing landscape.
Moving beyond the individual level, as a society of clinicians, I believe, we should continue to support legislation on price transparency and against surprise/inappropriate billing. While preparing for this article, I spoke with one clinician who was overbilled for medical care and the overcharge was not returned for months until the clinician discovered an account “credit” buried in her patient portal and inquired further. In my ideal world, billing departments would have to return overcharges with credit-card level interest and could face stiff penalties for inappropriately sending patients to collections. Unfortunately, legislation can have unforeseen negative consequences in the worst of scenarios. In the best cases, effective legislation still requires time, money, and energy to implement.
As clinicians, we could also strive to avoid working for employers notorious for their bad billing practices, but access to such information seems limited. However, if an entity started requiring the release of data on billing practices, then clinicians could better decide if a potential employer’s approach to billing aligns with their own philosophies in providing health care. Similarly, we could advocate that these patient billing metrics, or appropriate surrogate markers, become part of nationwide annual rankings or are otherwise made publicly available. For instance, as a patient and as a clinician, I would certainly be interested in knowing if a certain hospital system in my area was in the top 1% nationwide for sending their patients to collections or was an outlier in having insurance claims denied. Having these data available and broken down by demographics and/or insurance type would also reveal if certain demographics are being targeted more than others.
So where does that leave us today? Well, first, I’d remind all clinicians of the important interplay between patient care and finances related to that care. We’d all agree that this relationship exists and factors into patient care whether we like it or not. Second, I’d reemphasize the steps we can all take on a personal level to drive immediate change and that continued legislative support can portend future change. Last, I’d put forth a call to action to have financial components of care publicly reported and/or included in national ranking systems. The patient’s experience does not end at discharge, and we must do our due diligence on their behalf.
What do you think should be changed with billing patients? Share in the comments.
Kyle Walker, MD, MBA, is an orthopaedic surgeon who is currently training as the Sarcoma Advanced Research and Clinical Fellowship at U.C. Davis in Sacramento. He enjoys skiing, tennis, and spending time at the pool with his wife and two sons. He can be found on instagram at @kywalkermd. Dr. Walker is a 2023–2024 Doximity Op-Med Fellow.
Image by Oksana Latysheva / Getty
