Common Medical Billing Errors and How to Spot Them 

Few things are more jarring than receiving a medical bill that is much higher than expected. Whether it’s a surprise charge for a procedure you thought was covered or a seemingly unexplained fee from a visit you thought was routine, these bills can feel like an emotional and financial punch.

The problem is that medical billing is notoriously complex. Charges often come with codes, jargon, and descriptions that are nearly impossible to decipher without specialized knowledge. Unfortunately, this complexity can leave you vulnerable to overcharges or mistaken charges that may go unnoticed if you don’t know how to navigate the bill.

In this article, we’ll take you through the process of reading and understanding your medical bills, explain how these charges are structured, and most importantly, provide actionable tips on how to dispute unexpected charges that don’t seem right. The more informed you are, the better equipped you’ll be to avoid paying for something you shouldn’t—and to ensure you’re not taken advantage of in a system that’s often opaque and frustrating.

What’s Inside Your Medical Bills and What it Means

When you receive a medical bill, it might look like an overwhelming jumble of numbers, codes, and descriptions. But beneath the surface, it’s just a detailed record of your medical treatment, billing codes, and charges. Let’s break down the key components of a typical medical bill so you can start understanding what you’re actually being charged for:

Provider Information

This section lists the doctor’s office, hospital, or clinic that provided the service, along with their contact information. It will also include the date of service and often a patient account number for easy reference.

Patient Information

This includes your name, your insurance information, and the type of insurance plan you have. Sometimes, your insurance provider will also be listed here.

Description of Services

This is where things can get complicated. Instead of being a simple list of procedures, tests, or services, this section usually includes a combination of codes (known as CPT codes or ICD-10 codes) that are used by healthcare providers for insurance and record-keeping purposes.

Example: You might see something like “99213 – Office Visit, Established Patient.” These codes are standardized for billing purposes but can be hard for a layperson to interpret.

Charges for Services

This lists the charge for each service or procedure, often broken down by individual tests, doctor visits, or hospital stays. These charges might not match what you ultimately pay, depending on your insurance coverage and any discounts that apply.

Adjustments and Insurance Payments

If your insurance plan has covered part of the cost, this section will show the amount your insurer paid and any adjustments (discounts, negotiated rates, etc.). This will also include any deductible or coinsurance payments that you need to cover.

Total Amount Due

Finally, this will tell you what’s left for you to pay. The total amount is what you owe after your insurance has paid its portion, considering any adjustments.

Common Medical Billing Mistakes and How to Spot Them

Medical billing errors are more common than you might think. In fact, it’s estimated that 80% of medical bills contain errors. Whether these errors are caused by administrative mistakes, incorrect coding, or miscommunication between providers and insurers, the burden often falls on the patient to identify and challenge these errors. This highlights a lack of accountability on the part of billers that should be addressed.

Here are some of the most common billing mistakes to watch out for:

Duplicate Charges

Duplicate charges occur when you are billed twice for the same medical service. This error can arise from various sources, including:

• Clerical errors: Mistakes made during data entry or billing processing can lead to duplicate charges. For instance, a biller might accidentally enter the same charge twice, or a computer system could glitch and generate a duplicate bill.
  
  
• Duplicate claims: Healthcare providers might unintentionally submit the same claim multiple times to your insurance company or to you directly. This can happen due to miscommunication, technical issues with claim submission systems, or confusion about the status of a previously submitted claim.
  
  
• Provider errors: In some cases, a healthcare provider might mistakenly bill you for a service that was already included in a bundled payment or for a service that was not actually provided.

Identifying Duplicate Charges

• Carefully review your medical bills: Look for identical or very similar charges listed on the same bill or on multiple bills for the same date of service.
  
  
• Compare your medical bills to your explanation of benefits (EOB) statements: Your EOB statements from your insurance company can help you verify which services were billed and paid for.
  
  
• Check your bank and credit card statements: Look for duplicate charges from healthcare providers.

Incorrect Coding and its Impact on Medical Bills

Understanding the Coding Systems

• CPT Codes: These codes provide a standardized way to describe medical, surgical, and diagnostic services. Each procedure, from a simple office visit to a complex surgery, has a corresponding CPT code.
  
  
• ICD-10 Codes: These codes classify diseases, injuries, and other health conditions. They provide a detailed description of the patient’s diagnosis.

How Incorrect Coding Affects You

• Overcharging: If a procedure is coded incorrectly with a higher-paying code, you could be charged significantly more than what is warranted. This can lead to unexpected and exorbitant medical bills.
  
  
• Claim Denial: Insurance companies rely on accurate coding to process claims. If there’s a mismatch between the CPT and ICD-10 codes, your insurer might deny the claim, leaving you responsible for the entire cost.
  
  
• Out-of-Pocket Expenses: Even if the claim is not denied, incorrect coding can result in higher out-of-pocket costs due to incorrect application of deductibles, copayments, and coinsurance.

Common Coding Errors

• Upcoding: This occurs when a provider uses a code for a more expensive service than what was actually performed. This is often done to increase reimbursement from insurance companies.
  
  
• Unbundling: This involves billing separately for services that are typically bundled together under a single code. This can lead to inflated charges.
  
  
• Modifier Errors: Modifiers are added to CPT codes to provide additional information about the service. Incorrect use of modifiers can lead to billing errors.

Example of Coding Error

Unnecessary Services

There are instances where you might find yourself billed for services that you didn’t actually receive or that were not necessary for your medical care. This can happen due to a variety of reasons, including:

• Administrative Errors:  Mistakes can occur during the billing process, leading to incorrect items being added to your bill. This might involve a service that was ordered but not performed, or a charge that was duplicated accidentally.
  
  
• Miscommunication:  There could be a misunderstanding between you, your healthcare provider, and the billing department regarding the services you agreed to receive.
  
  
• Upcoding:  This is a fraudulent practice where a healthcare provider bills for a more expensive service than what was actually provided.
  
  
• Overlapping Services: In some cases, you might be charged for multiple services that address the same medical issue, when only one was necessary.

Example Scenarios

• If your doctor ordered a lab test but you opted out of the procedure, yet you’re still billed for it, there may be an error on your bill.
  
  
• You might be charged for a full consultation when you only had a brief phone call with your doctor.
  
  
• You could receive separate bills for an X-ray and an MRI, when only one imaging test was needed to diagnose your condition.

It’s crucial to carefully review your medical bills and ensure that all the charges are accurate and justified. If you find any discrepancies or charges for services you didn’t receive, you should contact your healthcare provider or the billing department immediately to dispute the charges.

Out-of-Network Charges

Out-of-network charges can be a significant source of unexpected medical bills. These charges occur when you receive care from a healthcare provider, facility, or service that is not within your insurance plan’s network. 

These charges can be substantially higher than in-network costs, as out-of-network providers do not have negotiated rates with your insurance company. This means you may be responsible for a larger portion of the bill, even if you have insurance.

It is crucial to be aware of the distinction between in-network and out-of-network providers and to confirm that all aspects of your care, including lab work, specialists, and ancillary services, are being provided by in-network professionals. This is especially important when receiving care at an in-network facility, as some services within that facility may still be provided by out-of-network providers.

Here are some common scenarios where you might incur out-of-network charges:

• Emergency services: In emergency situations, you may be taken to the nearest hospital, which may not be in your network. Additionally, some emergency services, such as ambulance transport or certain specialists, may be out-of-network even at an in-network hospital.
  
  
• Referrals: Even if your primary care physician is in-network, they may refer you to a specialist who is out-of-network. It’s crucial to confirm the network status of any specialist before receiving care.
  
  
• Ancillary services: Certain services provided during a hospital stay, such as anesthesia, radiology, or pathology, may be performed by out-of-network providers, even if the hospital itself is in-network.
  
  
• Lab work: If your blood work or other lab tests are sent to an out-of-network laboratory, you may receive an unexpected bill.

Here is an example of how out-of-network charges can arise:

You go to an in-network hospital for a surgical procedure. The hospital itself is in-network, but the anesthesiologist who administers your anesthesia is out-of-network. As a result, you may receive a separate bill from the anesthesiologist that is not covered by your insurance at the in-network rate, leaving you responsible for a significant portion of the cost.

Remember to be aware of your insurance coverage and to confirm that all healthcare providers and services you receive are within your network. If you have any questions or concerns about the network status of a provider or service, contact your insurance company for clarification.

Conclusion: Take Control of Your Medical Billing Experience

Medical billing may seem daunting, but with the right knowledge and tools, you can turn a frustrating process into an opportunity to protect your finances and advocate for fairness. Understanding the structure of your medical bills, recognizing common errors, and knowing how to address discrepancies are critical steps to ensuring you only pay what you owe.

Healthcare billing is notoriously opaque, but by staying proactive—requesting itemized bills, verifying insurance coverage, and questioning any charges that seem off—you can navigate the system with confidence. Remember, mistakes are common, and billing departments and insurers are not infallible. The more you engage, the better your chances of resolving errors quickly and effectively.

Empower yourself with these insights and take the steps necessary to regain control of your healthcare costs. By doing so, you’ll not only safeguard your financial well-being but also help hold the system accountable for delivering transparency and fairness. Your health and peace of mind are worth the effort.