Cite HIPAA to Obtain Your Itemized Medical Bill and Billing Codes.

The federal privacy law requires medical providers and insurers to give patients their billing records. I've provided a helpful written template in this newsletter.

My friend Kay texted me the other day with an aggravating problem. She was getting the medical billing runaround.

What’s the medical billing runaround? It’s the vortex that entraps patients when their medical providers and insurance companies are passing the buck instead of correcting billing mistakes. You know you’re getting the medical billing runaround when you’re slogging through misinformation, you’re mired in robo-phone directories, and you’re being bound by ridiculous red tape. When you realize that the “customer service” representatives don’t have a clue or a care about solving your problem - that’s the medical billing runaround.

If you’re a living, breathing, American – you almost certainly know the medical billing runaround. It’s a big part of the reason I wrote my book, “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.”

Kay had spent a day on the phone getting bounced between the hospital billing department and insurance customer service reps. She still couldn’t get the information she needed. She was in the medical billing spin cycle and needed help.    

I shared a tactic with Kay that can help her, and you, get clear information about your medical bills. Federal law gives patients the right to obtain their health information – and that includes billing information. This method won’t solve all your billing problems. But it can help provide the clarity you need to assess whether to pay a bill or contest it.

Kay gave birth to a beautiful baby girl last April, which illustrates how inept hospital billing can be. There’s no reason this should be going on this long. She set up a payment plan with the hospital in December to pay off about $1,100 over three equal installments. She made her first two payments and all seemed well. Then, a few weeks ago, the hospital sent a new bill, listing the same services, that did not reflect the two payments Kay had already made.

This should have been an easy one to correct. Kay has the records to show that she made the two payments. But somehow neither her hospital, nor her insurance company, would correct the problem. Furthermore, they would not provide the details she needed to understand the issue – even after hours of trying. And of course, she was hassling with this while caring for her two small children. “All day I’ve been dealing with this,” she texted me.

It appeared to Kay that she was being billed twice for the same services, but it was hard to tell because her medical bills were too vague.

The first piece of advice I give in these situations is to get an itemized medical bill — and make sure it includes the billing codes. Often that’s easy to do. But Kay’s hospital only provided a summary of the charges. The breakdown tallied up things like “room charges” and “lab tests” and “self-administered drugs.” But it did not detail each individual charge that made up the total. That would be like your grocery store receipt showing aggregate charges for “dairy products” or “meat products,” without saying the price of individual items like milk, cheese and ground beef. Checking your itemized medical bill ensures you were only charged for services you received, and helps you make sure the prices are fair. (I show how to do this in my book.)

In addition, Kay’s summary of her hospital charges did not include billing codes. The billing codes are the lexicon that’s used to translate medical records into medical claims, which get submitted to insurance companies and turned into medical bills. You need the billing codes to check the specific charges that were applied to each service.

Kay’s hospital billing department and insurance company were hemming and hawing, wasting her time. She could not get the detailed information she needed and felt incensed. In other cases, I have heard from patients who are told the itemized bill with billing codes is “not available.” Or patients have been told they are “not allowed” to have the information.

Nothing could be further from the truth. The Health Insurance Portability and Accountability Act of 1996, better known as HIPAA, gives patients the right to obtain the private health information that their medical providers and insurance plan have gathered about them. And that private health information includes medical information and billing information. 

I wrote last week about how insured patients can deploy HIPAA if they want to pay the cash price. HIPAA also ensures patients can obtain their billing records. Look how clearly the federal Department of Health and Human Services articulates your rights under HIPAA to your own private health information (PHI):

To sum it up: A patient has a right to the records about their care that are maintained by entities that are covered by HIPAA, like hospitals and insurance plans. This includes medical and billing records, and records about enrollment, payment, claims adjudication and case or medical management record systems. Withholding this information is a violation of federal law. Thus, we can cite the HIPAA law to gain access to our itemized medical bills and billing codes.

There’s tremendous power in citing HIPAA. Doctors and hospitals and other medical providers have had HIPAA compliance drilled into their heads. But typically, the medical providers have looked at their own HIPAA compliance from the narrow perspective of making sure private health information doesn’t get into the wrong hands. That’s important, but the law gives patients additional rights. Citing HIPAA to obtain our records can cut through the medical billing runaround.

Citing HIPAA is also powerful because it’s enforced, with penalties. Here’s the online site where you can file a HIPAA complaint with the Office for Civil Rights. If your information is being withheld, file a complaint. This could help spur them toward fulfilling your request.

Often, you can get an itemized bill with the billing codes without a lot of hassle. But if you’re getting the runaround, I would not waste time trying to convince anyone over the phone. Put it in writing. This raises the formality and importance of your request. It also creates a paper trail in case you need it for your HIPAA complaint. Send your written request to whatever email the customer service reps provide. Also, look up the administrators and leaders of the entity billing you and send them your request. If you have a flair for the dramatic, you can also print your request and bring it to the front desk at whatever entity is billing you. Then find a supervisor and politely ask that person to sign your document to acknowledge receipt of it. That alone could create the kerfuffle you need for them to give you the information.

Here’s a template I wrote that you could use as a starting point for your own request:  

“Dear [BILLING DEPARTMENT or INSURANCE COMPANY],

I have been asking over the phone for you to provide me with an itemized medical bill that lists each of the charges related to [the episode of care that’s the source of the medical bill], including the billing codes.

The Health Insurance Portability and Accountability Act of 1996, the federal law better known as HIPAA, gives me the right to my Private Health Information, and that includes my claims and bills. It’s a violation of HIPAA for you to withhold this information. See here for more information: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html

This is my formal request for you to immediately provide this information so I can verify that you accurately and fairly billed me for this episode of care. If you do not comply with my HIPAA rights, you will leave me no option but to file a complaint against you with the Office for Civil Rights.

You should have these records in electronic form, so please email them to me at [YOUR EMAIL ADDRESS]. They should also be easy for you to access, so there should be no charge for your compliance with this federal law.

Sincerely,

[YOUR NAME]

***

Kay last spoke to the hospital billers and insurance company a few days ago and said she would pick it up again this week. Her plan now includes citing HIPAA and putting her request in writing. Digging into her bills is a pain, but she knows that there are hundreds of dollars at stake, maybe even more. So she will check the charges to make sure they are correct. “If I can follow the math and add it all up, I will pay the bill,” she said. “I need to just see the numbers add up before any money leaves my bank account.”

It’s unfortunate that medical billers and insurance companies sometimes give patients the runaround. But it’s so common that we need to learn to assert ourselves. Fortunately, federal law is on our side. We just need to press our health care providers to abide by it.

As always, if you have a Victory Story for me, please share it. And feel free to reach out if there’s a problem where I can be of assistance.

“Never Pay the First Bill,” featured Amazon review:

If you haven’t already, get your copy of “Never Pay the First Bill.” If you’re interested in making a bulk order, please contact me. The discounts are great!

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