Billing nuances

Kaiser Health News published a piece on how a slight difference in how a procedure was billed made a significant financial difference for the patient. As background, the Affordable Care Act mandated that certain preventative care procedures (e.g. routine check-ups) would not cost insured patients anything out-of-pocket with the hope that more people would undergo preventative care and avoid more costly care. A screening colonoscopy is an example of such preventative care procedures. However, diagnostic colonoscopies -- which might be prescribed to determine if a patient has colon cancer -- can still be billed as non-preventative care, thereby costing some patients. Presumably, healthcare providers get paid much more for diagnostic colonoscopies than they do for screening colonoscopies, tempting many to bill for the more profitable procedure. In turn, Medicare has clarified that the removal of a polyp (relevant to the patient's colonoscopy described in the article) does not warrant changing a screening colonoscopy to a diagnostic one. However, it seems like some providers persist in the more lucrative billing. In this particular piece, the patient expected her colonoscopy to be a screening procedure and therefore not to cost her anything. She was billed over $2,000, and the provider persisted in billing her procedure as diagnostic rather than as screening (even when a representative from the insurance company was present). After being contacted by Kaiser Health News, the provider admitted making a mistake and re-submitted the procedure as a screening colonoscopy.

While this case was resolved in favor of the patient, it is unfortunate that the provider admitted to making a mistake only after media's involvement. There must be many, many other cases in which media does not get involved, and patients might have little practical recourse when providers insist they are correct.