My wife received a bill last week from Simon Medical Services for $90.22, part of the cost of a brace her doctor gave her for her broken foot.
This confused me because our health insurance, Tufts HMO, usually provides 100% coverage after copayments.
I looked up the claim on the Tufts web site and found the following:
- Simon billed Tufts $285.00.
- Tufts “allowed” $278.26.
- Tufts paid 70% of the allowed amount, i.e., $194.78 (a representative of Tufts subsequently explained to me that our policy provides only 70% coverage for “durable medical equipment”).
- We were liable for the remaining 30%, i.e., $83.48, of the allowed amount.
Insurance companies such as Tufts negotiate agreements with service providers like Simon. These agreements dictate how much the providers are allowed to charge for various services. When a service is discounted because of the agreement between the insurance company and provider, the provider is required to write off the discount; they are most certainly not allowed to ask the patient to pay it.
Nevertheless, that is exactly what Simon did. Tufts told them they were allowed to charge a total of only $278.26 for my wife’s leg brace, but instead of billing my wife for $278.26 – $194.78 as they should have, they billed her for $285.00 – $194.78.
The amount we’re dealing with in this particular incident is small. However, consider that:
- An error like this is never an isolated occurrence. If Simon over-billed my wife, then you can be 100% certain they have over-billed other patients as well and will continue to do so unless something is done to put a stop to it.
- Most people who receive medical bills in the mail pay them without checking whether they’re correct or not.
- Because over-billing is lucrative for the provider and rarely detected by patients, there is a strong disincentive for providers to prevent it from occurring.
When I contacted Tufts about this, they confirmed that we were over-billed. They said they had contacted Simon about the error, and Simon reduced our balance due to the correct amount. Tufts also said “the provider communicated an apology for the mistake.”
I appreciate the apology. However, I think it’s unlikely that Simon has taken any steps in response to our complaint to find out what other patients have been over-billed, apologize (and refund) to them as well, and put measures in place to prevent it from happening in the future.
I have asked Tufts what steps, if any, then plan to take to review Simon’s billing of other Tufts patients so that past over-billing errors can be corrected and future ones prevented. When/if I hear back from them, I will post their response here.
I also intend to send a link to this blog posting to Simon and offer them an opportunity to respond.
There is an important moral to this story: carefully check every bill you receive from a medical service provider. Doing so will both protect you from being overcharged, and enable you to put pressure on the providers doing the overcharging to amend their ways. Preventing over-billing doesn’t just keep more money in your pocket; it helps to keep healthcare costs down for everyone.