Medical bills can sometimes seem confusing, but maybe you have noticed bills you were not sure you should pay.
According to health care experts, sometimes a patient may receive surprise medical bills due to balance billing, which means a hospital bills a patient for any expenses that are supposed to be covered by insurance.
Balance billing can be caused by a number of scenarios, ranging from a hospital billing error to a piece of equipment used in a procedure not covered by your insurance plan, according to health care watchdog groups.
One local man, Johnny Hale, is currently fighting surprise medical bills after recovering from a stroke three years ago. Part of his treatment involved out-patient rehab.
“I had a lot of trouble with perception on my left side,” he explained. “And they worked with that part of it – trying to get me to work to the left.”
Hale went for physical, occupational and speech therapy after his stroke at a local hospital.
Officials with the hospital told him his out-patient therapy would be covered by insurance, he said, but a few months into his treatment, some unexpected medical bills started arriving in the mail.
Among them was a bill totaling more than $5,000 for speech therapy.
“They never told me it wasn’t going to be covered,” Hale said. “They told me that, ‘We’ve got you approved for so many visits.'”
For this report, we have agreed with Hale to withhold the name of the hospital and his insurance company since the matter is still being resolved.
When Hale reached out to his insurance company, he said he was told the bills he was receiving would not be covered, so he had no choice but to give up the therapy.
“I knew I couldn’t pay it – way over my head,” Hale said. “I’m retired and disabled and can’t work, so I was in trouble.”
“He was being billed for services that I didn’t feel he should be getting billed for, which is what balance billing is,” said Christie Hudson, vice president of health care advocacy group Medical Recovery Services. “It’s when a patient is being billed for services that should be covered.”
Hudson and her mother Pat Palmer, the founder of Medical Recovery Services, took on Hale’s case.
“This is a huge problem, according to the response we’re getting from consumers throughout the country,” Palmer said.
After reaching out to the hospital, Medical Recovery Services found that many of the bills were for co-payments that were not requested at the time of treatment, Hudson said.
“Typically, if you have a co-pay, you’re asked to pay that up front, which he [was] not, so he assumed that he didn’t have to pay anything,” Hudson said. “And then the visits went on and on and on, visit after visit, while the whole time he was building a bill and had no idea.”
As for that $5,000 speech therapy bill, Hudson said the treatment was not labeled as medically necessary by the hospital, so it could not be covered by insurance.
“He had suffered from a stroke, so it was a medically necessary service the doctor had suggested that he go through,” she said.
The blame for problems like this often lands on the billing departments of hospitals and providers, Hudson said.
“They’re responsible for making sure the claim gets filed correctly so that it can get paid so that it doesn’t fall back on the patient,” she said.
“A lot of patients come to us, feel like it’s just an isolated incident for them,” Palmer said.
Palmer suggests patients request a detailed itemized statement from the hospital following treatment, which provides a breakdown of the services and charges.
“When you get a bill, and you owe something on that bill more than a co-pay amount, you absolutely have to investigate that bill,” Palmer said.
She also urges patients to discuss the treatment costs with their health care providers in advance, if possible.
“If it’s something you feel you don’t owe, you should pursue in questioning, and I recommend it in writing because what you’re told over the phone is most likely not something that’s going to get put in writing,” Palmer said.
As for Johnny Hale’s case, there has been some progress. Hale does not hear from collection groups anymore, Hudson said, adding that she feels a resolution looks promising.
“I’d like to see the bill taken care of, get things straight, get it paid off or whatever I got to do,” Hale said. “A reasonable amount. I don’t want to pay that kind of money.”
Medical Recovery Services tries to get balance billing issues resolved within 60 days but sometimes are forced to pursue legal action if it’s taking longer to reach a solution, Palmer said. Eight out of every ten medical bills brought to her company have errors that are not in the patient’s favor, she added.
State laws vary on balance billing. As for Virginia, we reached out the the state attorney general’s office, which did not respond to our request for an interview.
We also reached out to a handful of local attorneys and state legislators who told us they do not believe there are any laws in Virginia that would protect a patient from balance billing.