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How to crack medical bill codes

By Candice Madsen and Mike Headrick, | Posted - Jul 22nd, 2013 @ 10:16pm

OREM — If you've ever had to deal with large medical bills, you probably know the pain of trying to make sense of all the charges.

Orem resident Ruth Cuell received a bill for an ambulance ride that she didn't think was fair. A KSL investigation revealed that when it comes to cracking medical codes, the bill doesn't always tell the full story.

Cuell's son Tyler is a healthy 8-year-old now. But in October, a large and mysterious mass caused him all sorts of trouble.

"That afternoon he collapsed in pain," Cuell said.

Doctors at Timpanogos Hospital in Orem wanted to remove his appendix.

"They were guessing it was his appendix but it wasn't in the area of the appendix," Cuell said.

They finally decided Tyler needed to go to Primary Children's Medical Center. Doctors said he had to go by ambulance.

"We said,'We don't have great insurance, so we'll just take him up to Primary Children's,' and they said that 'We cannot let you do that.' They said if it is his appendix and he does go septic, he is going to need immediate care," Cuell said.

Tyler didn't receive any kind of medical treatment in the ambulance and the sirens were not used. That's why she was shocked when she received a bill for $2347.64, she said.

10 Tips for cracking the mystery of medical codes
    1. Understand the insurance policy. A lot of policies have specific requirements for ambulance coverage and emergency room visits.

    2. Ask for an itemized bill so you can see every charge and check it for errors.

    3. Get a written explanation of any disputed charges. Figure out who coded the bill and what information they were given from doctors and nurses.

    4. Question charges for what seem like routine items that should have been included as part of the facility fee.

    5. Check the bill for upcoding. This occurs when a code for a more severe diagnosis or treatment is used, resulting in a higher bill.

    6. Check the bill for unbundling. This occurs when several services that should be packaged together at a cheaper rate are listed separately at higher rates.

    7. When dealing with a billing department, ask for a supervisor or someone capable of making a decision.

    8. Be polite. The billing department is going off of the information they received. Getting angry with them will not help your case.

    9. Ask for an uninsured discount or try to negotiate the price based on what an insurance company would have paid.

    10. Involve a third party or professional medical bill reviewer. They should only charge you if they are able to save you money.

The state of Utah regulates how much an ambulance service can charge. The base rate is approximately $600, plus a mileage charge of $30 per mile.

There can also be additional charges, and that is where things get tricky.

Medical bill expert Jay Whitehead showed KSL all of the ambulance codes. He's a managing partner for Advantage Medical Bill Review and helps people interpret their bills and make sense of all the codes.

KSL asked Whitehead if he would be satisfied with the information on the bill the Cuells received.

"No, I would not be satisfied at all," he said.

Most medical bills tell you what you owe but don't provide an itemized list of charges. In this case, the bill for the ambulance ride had two charges: ALS (Advance Life Support) Non-emergency for $1148.00 and a mileage charge of $1199.64.

With Jay's help, KSL figured out the Cuells were charged extra because Orem City's ambulance service was told Tyler's case was serious and they sent not one, but two paramedics.

"But all they did was give us a lift," Cuell said.

The family's insurance refused to pay the ride because it was coded as a non-emergency.

"I think the fact that we are in an ambulance period qualifies as an emergency," she said.

Whitehead explained that patients do not have to accept the initial bill as the final word.

"They need to dig and dig and dig," he said.

Medical bills are notorious for mistakes because of the complicated coding. A 2012 study by the American Medical Association found that while billing accuracy has improved, one in 10 bills paid by private health insurance have at least one mistake.

Whitehead said patients should ask for an itemized bill that will give a lot more information than the summation bill most patients are given.

"They have to tell you. They can't hide it," he said.

Whitehead advised the Cuell family to go back to the hospital and ask the doctors and nurses about what they said when they ordered the ambulance. They've taken the advice and are getting more information they can give their insurance company.

As for Tyler's mysterious mass, it was a piece of liver with a fatty tissue tail that was twisting in his bowels. Dr. David Skarda at Primary Children's Medical Center said it was an extraordinarily rare case. He's never seen another case like it.

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