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.
When asked to comment on this article, Simon Medical Services responded as follows:
Yes, that’s really their entire response.
I’ve written to Tufts twice now, asking what they’re doing about ensuring that this service provider does not over-bill other customers in the future, and they have not responded. *sigh*
I got screwed in a similar way by my dentist… my wife had a filling partially fall out, so the dentist replaced it with a temporary resin cap until he had time to book us for a full-on fix. Somehow Delta Dental decided that he should have done some other procedure for 1/3rd the cost, and stuck us with the bill for the difference. Delta only ended up covering like $50 of this $300 procedure because of the copay and difference in price.
How the hell are we supposed to know what dental procedures are covered by our insurance? Or even what dental procedures need to be done in any particular situation? It’s ridiculous…. I’m mad at both Tufts for refusing to pay for what seemed like a routine procedure, and the dentist for not letting us know that Delta might not cover it (and there’s NO WAY they don’t know… Delta is far and away the most common dental insurance around here, and the dentist is the one that sends the bills letting patients know their insurance didn’t cover something).
I think you meant “Delta” above when you wrote “Tufts”.
In any case, I don’t think Delta was at fault. Your dentist is supposed to know what Delta does and doesn’t cover, and he’s supposed to let you know when there is a coverage issue. If there are multiple possible treatments with different coverage levels, he’s supposed to discuss them with you before proceeding with treatment.
This has happened to us on multiple occasions with our kids’ dental treatments, i.e., the dentist has let us know that something he thought was the right thing to do would be covered at a lower rate by Delta. In each case, he discussed the alternatives with us and explained why he felt the treatment he was recommending was appropriate, and we had him proceed with the treatment he was suggesting despite the reduced coverage from Delta.
If your dentist didn’t do that with you, then I certainly hope you complained to him about it. If you did, and you didn’t get the impression that he was receptive to your complaint, you might want to find another dentist, because it’s bound to happen again.
Note that what you’re describing is different from what happened to my wife with Simon. Your dentist didn’t over-bill you for a service that he had previously agreed with Delta to charge less for. He performed a different service than the one Delta felt was necessary for the condition being treated. In that context, Delta only pays for what they feel was the necessary service.
Note that Delta Dental has a specific policy about resin fillings which is probably what caused your problem. Your dentist certainly should have told you in advance if that was going to happen.
If that’s not what happened, then you might consider appealing Delta’s coverage decision, if you can get your dentist’s cooperation in making a case to Delta that the treatment he chose was necessary and appropriate.