A Billing “Never Event”

In medical terms, a “Never Event” is an event that should never happen, like a wrong site surgery or killing a patient. An article in today’s medical reading clearly demonstrates a real time Billing Never Event, that unfortunately occurs much too often in medical clinics.

According to WCPOin Cincinnati (OH), a mom had to be pay a bill before her daughter would be seen at a walk in clinic.

The story begins: 

“Jessica Vance wanted to avoid a $1,000-plus emergency room bill, when her 8-year old daughter recently developed a cough and fever. 

So she took her to a walk-in clinic inside a local grocery store.”

Problem number one: Why doesn’t this family have a Family Practice Doctor? One of the cited reasons for America’s high health costs is the use of Emergency Rooms for non-emergent conditions, such as this case. If mom had established herself with a Family Practice Doctor, she would have either been seen that day, or at the very least prescribed a medication with a follow up visit, for the cost of a co-payment.

But I digress, let’s continue the saga:

“But when Vance spoke to the woman at the desk, she received some stunning news. The employee said Vance had a $690 unpaid balance, from an insurance payment that had not yet processed.

So the employee said Vance’s daughter could not see the nurse, and suggested they go to an emergency room if they needed immediate help.

“I said ‘what do you mean you won’t see her?’ Vance said. “They told me I have a balance due. I asked them ‘can’t you call insurance?’ They said no, they could not.”

So reluctantly she put the past due amount on her credit card, rather than drive across town to an emergency room, and a much larger bill.

“I ended up having to pay $690 that day for her to be seen,” Vance said.”

This is where the clinic made its mistake, and it is a huge mistake. Yes, clinics, doctors, etc. can refuse care for non-emergent cases when the patient has a balance due. However, in this case there was not a balance due. Let’s look at the sentence again:

“Vance had a $690 unpaid balance, from an insurance payment that had not yet processed”

If the claim had not yet been processed by the insurance company, there is no balance for the patient to pay. When a medical entity agrees to be an in-network provider, which means that the entity agrees in a contract to submit claims to an insurance company for payment and not collect from the patient at time of service, then the patient cannot be billed for any monies owed until that claim is processed. The clinic violated the contract with the Insurance Company and as such the Insurance Company has grounds to nullify that contract, resulting in the clinic becoming a non-participating provider.

Now to make matters worse, the article reports that the Insurance Company paid the balance due in full but mom has not yet been reimbursed the funds. This is the ultimate insult.

While a clinic has a right to deny treatment based on an unpaid balance, the patient would have to be notified in writing that this was the policy and the patient would have to sign a document acknowledging that policy. (When I manage an office, my Policy and Procedure Contract with Patients is about 11 pages long.) Without that signed documentation, the clinic cannot deny treatment based on monies due, as this is outside the contract that the Patient and the Insurance Company have with the provider.