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Fighting Unscrupulous Medical Billing Tactics by Insurers

Tuesday, January 24, 2017By Richard Alexander

If you’ve ever had a hospital stay or emergency medical procedure, you might be familiar with the sticker shock that accompanies the subsequent bill. Since many insurance companies are notorious for employing unscrupulous strategies and tactics to reprice medical bills in efforts to minimize or eliminate damages owed to claimants, it’s important to know how to recognize these techniques and how to fight them. Listed below are the top five tactics that insurance companies use to reprice medical bills.

How Insurance Companies Reprice Medical Bills

  1. Improper and inappropriate sources used for establishing reasonableness of charge.
  2. Mixing the use of “allowed” and “reasonable” for billing purposes.
  3. Inability of insurer to properly code a charge that is difficult for them to measure.
  4. Outright suppression of critical and supporting information to the bill.
  5. Using completely irrelevant third-party payment terms.

Inappropriate Sources for Establishing a Reasonable Charge

We frequently see insurance companies try to use inappropriate sources to establish the reasonableness of charges. They will used improper physician fee schedules or use paid or reimbursed amounts to compare with billed charges. Make sure to investigate the sources used in establishing reasonableness for your medical bill charges.

Mixing Up “Allowed” and “Reasonable”

This tactic is used when insurance companies employ the “lesser of” method of repricing charges. They use this unscrupulous technique to find charges unreasonable when one provider’s bill might be slightly higher. Look at line items and analyze their amounts to determine if insurers are using this method to reprice your medical bill.

Inability to Properly Code a Difficult-to-Measure Charge

If an insurer has an inability to easily code a charge that might be difficult for them to measure, they’re likely to disregard it all together. This is a fault with their inadequate system and billing procedure, and you shouldn’t have to be on the hook for that charge. Ask your provider for a statement of the charges and services to help establish reasonableness.

Suppressing Important Information

If there is no analysis, supporting data or additional mention of billing methods and tactics, your insurer could be suppressing important information and at worse defrauding you and others. Always ask for additional supporting information and reports when given ridiculously repriced medical bills.

Irrelevant Third-Party Terms

Finally, don’t let irrelevant third-party payment terms crank up your bill. It can be difficult to understand when reading medical bills, but sometimes certain procedures and items are bundled together, and a ruthless insurance company might wield those irrelevant third-payment payment terms in their own best interest, regardless of the facts.

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