Have you ever spent what seems like hours in a waiting room, for what ends up being a medical visit lasting just minutes? Was the medical bill you received weeks later much higher than expected?
That bloated bill may be due to an illegal practice called upcoding.
Upcoding is when your health care provider overcharges for health care services you received.
“It’s not fraud in the sense that they billed you for, for services that never happened at all. It’s that they billed you more for services than they should have,” explains Adam Sacarny, an assistant professor of health policy at Columbia Mailman School of Public Health.
Imagine, you go to your provider to treat a sore throat.
The doctor comes in, tests you for strep throat and prescribes antibiotics. The appointment takes no more than 15 minutes, but they charge you for an hour-long complex visit.
A situation may be an example of upcoding, but it's hard to catch.
For one thing, the bill you get in the mail may not list all your charges. Sacarny says, if you’re skeptical, it’s worth investigating.
“If your bill is more of a summary bill, you can reach out to them and request a detailed bill with kind of line-by-line level services,” he says. “You can also get a copy of the bill from your insurer. It would be called an Explanation of Benefits — or EOB.”
Even with a detailed invoice, medical bills can still be confusing.
When you go to the grocery store, your receipt clearly lists each item you paid for, but with medical bills they use a system of medical codes that can be hard to decipher.
The good news is a simple online search can help you decode your services.
“That can really help you when you’re trying to figure out if it looks like the code was more or less appropriate for the visit,” says Sacarny.
Experts suggest it’s good practice to take a closer look at your bill.
“There are estimates for fraud in the health care system that suggest that it is extremely common. So it is it is not unreasonable to be concerned that you might have experienced up coding,” Sacarny says.
But keep in mind, not every large bill is a sign of upcoding.
“There’s more to the code than just the number of minutes,” explains Sacarny.
Even if you only saw the doctor for five minutes, if your symptoms were complex or difficult to diagnose, you may be billed at a higher rate.
Still, if you’re asked to pay a surprisingly high bill for that time you had the sniffles, you may have been overcharged.
The first step, Sacarny says, is to not pay the bill, and to notify your provider that you intend to dispute the charges.
Look up the codes to see if the codes match the services you received. If they don’t, ask your provider to explain the additional charges, or to remove them from the bill.
“Often just starting the conversation. You can make some progress on getting the bill down a little bit,” says Sacarny.
You can also speak with your insurance provider. Tell them you believe you were wrongly billed.
The last option is to file a complaint with the state health care regulator.
Regardless of the steps you take, experts suggest it is important to always advocate for yourself.
“I think what’s really frustrating about all these issues that we’re talking about right now is they happen when you’re sick,” says Sacarny.
But while it may be the last thing you want to think about when you’re not feeling well, he says it may be worth the trouble in the long run. “The fact is that negotiating, pushing back when you get these large bills, it sometimes can really pay off.”
For one thing, the bill you get in the mail, may not list all your charges. Sacarny says, if you’re skeptical, it’s worth investigating.
“If your bill is more of a summary bill, you can reach out to them and request a detailed bill with kind of line by line level services,” he says. “You can also get a copy of the bill from your insurer. It would be called an Explanation of Benefits — or EOB.”
Even with a detailed invoice medical bills can still be confusing.
When you go to the grocery store your receipt clearly lists each item you paid for, but with medical bills they use a system of medical codes that can be hard to decipher.
The good news is a simple online search can help you decode your services.
“That can really help you when you're trying to figure out if it looks like the code was more or less appropriate for the visit,” says Sacarny.
Experts suggest it’s good practice to take a closer look at your bill.
“There are estimates for fraud in the health care system that suggest that it is extremely common. So it is it is not unreasonable to be concerned that you might have experienced up coding,” Sacarny says.
But keep in mind, not every large bill is a sign of upcoding.
“There's more to the code than just the number of minutes,” explains Sacarny.
Even if you only saw the doctor for five minutes, if your symptoms were complex or difficult to diagnose, you may be billed at a higher rate.
Still, if you’re asked to pay a surprisingly high bill for that time you had the sniffles, you may have been overcharged.
The first step, Sacarny says, is to not pay the bill, and to notify your provider that you intend to dispute the charges.
Look up the codes to see if the codes match the services you received. If they don’t, ask your provider to explain the additional charges, or to remove them from the bill.
"Often just starting the conversation. You can make some progress on getting the bill down a little bit,” says Sacarny.
You can also speak with your insurance provider. Tell them you believe you were wrongly billed.
The last option is to file a complaint with the state healthcare regulator.
Regardless of the steps you take, experts suggest it is important to always advocate for yourself.
“I think what's really frustrating about all these issues that we're talking about right now is they happen when you're sick,” says Sacarny.
But while it may be the last thing you want to think about when you're not feeling well, he says it may be worth the trouble in the long run. “The fact is that negotiating, pushing back when you get these large bills, it sometimes can really pay off.”