Healthcare Bills – an attempt to understand

My last bill from MGH, for a physical.

MGH Charlestown Health Center
Outpatient
Clinic Visit- Hospital $125.00
Clinic Visit- Physician $337.00
Lab Services- Hospital $737.00
Pharmacy $304.00
Preventive Care Services- Hospital $218.00
Vaccine Administration – Hospital $15.00
8/7/2015 Insurance Payments/Adjustments – NHP ($476.66) ($1,121.45)
Account Balance $137.89
I had a question some questions about the bill.  I sent and an email to billing.  I do not understand why they said, we can not reply to you because of hippa regulations.  You have to call in?
Your systems authorize and authenticate that I , Gary Johnson, am contacting MGH with a question.
Part of HIPPA is that the consumer has the right to get answers to his questions
I  do not understand many aspects about the bill.

I went to the Charlestown Clinic to get a physical.   How many people receiving a bill like this, for a physical performed at their local clinic could say, I now what Clinic Visit Hospital was for?

I do not understand how you can bill me over $1500 for a physical, however , you really want 476 + 137.

My interpretation is, this bill is is not accurate.  No attempt is made to communicate the true nature of the real bill in the document I am looking at.  My guess is that there is an institutional and industry blindness on what is perceived as accurate information.  It does not appear to me that Partners Healthcare cares if there bills make any sense.

Here is the Explanation of Benefits that my Insurance company provide online.

Claim Services
Line
Status
Procedure Code
Description
Units
Billed Amount
Allowed Amount
Deductible Amount
Copay Amount
Paid Amount
1
PAY
36415
Laboratory;ROUTINE VENIPUNCTURE
1.0000
$16.00
$5.66
$0.00
$0.00
$5.66
2
PAY
80048
Laboratory – Chemistry;METABOLIC PANEL TOTAL CA
1.0000
$102.00
$36.11
$0.00
$0.00
$36.11
3
PAY
80061
Laboratory – Chemistry;LIPID PANEL
1.0000
$163.00
$57.70
$0.00
$0.00
$57.70
4
PAY
84443
Laboratory – Chemistry;ASSAY THYROID STIM HORMONE
1.0000
$204.00
$72.22
$72.22
$0.00
$0.00
5
PAY
84450
Laboratory – Chemistry;TRANSFERASE (AST) (SGOT)
1.0000
$64.00
$22.66
$22.66
$0.00
$0.00
6
PAY
84460
Laboratory – Chemistry;ALANINE AMINO (ALT) (SGPT)
1.0000
$65.00
$23.01
$23.01
$0.00
$0.00
7
PAY
85025
Laboratory – Hematology;COMPLETE CBC W/AUTO DIFF WBC
1.0000
$97.00
$34.34
$0.00
$0.00
$34.34
8
PAY
81003
Laboratory – Urology;URINALYSIS AUTO W/O SCOPE
1.0000
$26.00
$9.20
$0.00
$0.00
$9.20
9
PAY
99211
Clinic;OFFICE/OUTPATIENT VISIT EST
1.0000
$125.00
$44.25
$0.00
$20.00
$24.25
10
PAY
90736
Drugs requiring detail codes;ZOSTER VACCINE HZV LIVE FOR SUBCUTANEOUS USE
1.0000
$304.00
$107.62
$0.00
$0.00
$107.62
11
PAY
99396
Preventative Care Services;PREV VISIT EST AGE 40-64
1.0000
$218.00
$77.17
$0.00
$0.00
$77.17
12
PAY
90471
Vaccine Administration;IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE
1.0000
$15.00
$5.31
$0.00
$0.00
$5.31
13
PAY
99396
Professional Fees – Clinic;PREV VISIT EST AGE 40-64
1.0000
$337.00
$119.30
$0.00
$0.00
$119.30
Can you find Clinic Visit Hospital?  How about matching up the other items.
I am pretty sure that trying to understand a medical bill might be a new psychiatric disorder. You need to be an auditor with medical billing knowledge, and have access to people who can answer questions about codes and procedures and internal processing, at both the provider of medical services and at your insurance company to really understand a modern medical bill and its associated Explanation of Benefits.   

The detailed bill from MGH follows.  The amounts match up with the EOB.  

MGHDetailBill1

 MGHDetailBill2
This is what my Insurance company advertises for what they cover.
  • Physical Exams/Check-Ups
    NHP covers routine physical exams that are appropriate to your age and sex. Keep in mind, if you need care from any provider, hospital, or clinic, your Primary Care Provider is able to assist you in coordinating these services.
  • Flu Shots and other Vaccinations
    All are covered at no cost to you.
My health care coverage is through NHP.  In all the literature I can find about my plan, its says preventive services are covered 100%.  When something is in doubt, contact your primary care physician.  So I am perplexed.  How can a physical, performed by my primary care physician, not be covered by my insurance?  Do you think the detail bill helps me answer that question?
 
Here is a not very helpful reply from MGH.  This is what they say was not covered.
‎
[services;  HC Assay of Thyroid Stimulating Hormone TH, HC Transferase Aspartate Amino Ast SGOT, HC Transferase Alanine Amino Alt SGPT,
HC Estab Pt - Low Level Visit)
‎
Here is another response from MGH  

I do note that your routine physical was not noted as the primary reason why you were seen and based upon the Explanation of Benefits from your insurance, they may have processed the charge for the facility/clinic fee under something other than the routine physical which you can contact them to confirm and if so, see if they can reprocess the charge under the routine physical.  The remaining charges that were applied to your responsibility as $20 copay and $117.89 deductible were for the labs that were completed during the exam.
‎
Varying on your insurance plan and policy, certain labs even done during a routine physical may not be fully covered and may apply to patient copay, co-insurance, or deductibles.  As we have no control over what plan you have choosen or what they plan allows for and pays varies, you need to contact them to get clarification.  You can ask if they did process these labs under the routine physical diagnoses or did they use another diagnoses.  Again, if they used anything other than the routine, see if they can reprocess these charges under the routine exam.  If they tell you that these are medically necessary procedural labs, please ask them if any of the diagnoses submitted with your claim can be used and if so, ask if they can reprocess claim under that diagnoses.
‎
The pharmacy charges were due to the vaccinations given during the visit.  An itemization of these charges have been requested and sent based upon the notes.  If you have any other questions or concerns, please contact us at 617-726-3884.

In all of this, do you see anything that would have given me a clue as to "MGH encoded the labs in some way that was not part of the physical"  This is my problem?  By the way, as far as I can tell Partners Healthcare owns both NHP and MGH.

Here is the response from NHP, my insurance provider.

Good afternoon Mr. Johnson,

Thank you for providing the additional information.

After reviewing the claim 15190E07022 submitted under provider Lydecke B. Sweet, the claim was processed correctly.

The claim was billed as a sick clinic visit also noted in the description Mass General Hospital provided you with. The primary diagnoses on your claim was listed as so below:

Diag: 272.4:   OTHER AND UNSPECIFIED HYPERLIPIDEMIA
Diag: 780.79: OTHER MALAISE AND FATIGUE
Diag: V70.0:   ROUTINE GENERAL MEDICAL EXAM@HEALTH CARE FACL
Diag: V04.89: NEED PROPH VACCINATION&INOCULAT OTH VIRAL DZ

Neighborhood Health Plan (NHP) was billed for multiple services. You do not have any financial responsibility for the Routine Services that were performed, however you are picking up a $20.00 copay for the clinic visit and $117.89 for your deductible due to 3 out of the 8 lab services that were billed.

Labs:
CPT: 84443
CPT: 84450
CPT: 84460

These 3 lab charges are not considered part of any Preventative visit which is why they generated a financial responsibility. Under your policy you have a $1,000.00 Deductible. If you have any Diagnostic services such as x-rays, ultrasounds, and or lab work they will go towards your Deductible and then you will not have any other financial responsibility.

I am attaching your Schedule of Benefits and Summary of Benefits and Coverage for you to further review in detail. I apologize for the confusion and any inconvenience this may have caused you.

The provider may submit a corrected claim if they billed NHP incorrectly, but from the notations it seems that this claim was billed correctly for the services that were rendered which include diagnostic services as well as preventative.

If you require further assistance, you may reply to this e-mail or contact the Customer Service at 1-800-462-5449.

I went digging a little deeper at Health and Human Services.

Please visit this link.  Its a US govt link
http://www.hhs.gov/news/press/2013pres/01/20130117b.html
Please see the line:

Individual rights are expanded in important ways.  Patients can ask for a copy of their electronic medical record in an electronic form.

MGH not only lies to patients about HIIPA guidelines.  They are not in compliance.

So I google around for the labs they say are not covered.

‎[services;  HC Assay of Thyroid Stimulating Hormone TH, HC Transferase Aspartate Amino Ast SGOT, HC Transferase Alanine Amino Alt SGPT, HC Estab Pt – Low Level Visit)

Is that 3 labs or 4 labs?
If I search for HC Transferase Aspartate Amino Ast SGOT

one of the hits I get is

http://www.webmd.com/digestive-disorders/aspartate-aminotransferase-ast

Why It Is Done

An aspartate aminotransferase (AST) test is done to:

  • Check for liver damage.
  • Help identify liver disease, especially hepatitis and cirrhosis. Liver disease may produce symptoms such as pain in the upper abdomen, nausea, vomiting, and sometimes jaundice.
  • Check on the success of treatment for liver disease.
  • Find out whether jaundice was caused by a blood disorder or liver disease.
  • Keep track of the effects of medicines that can damage the liver.

What is a physical for?  Is my liver not covered?

Here is a link to the published recommendations for preventative services for primary care physicians.

http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

It would be nice if I could figure out what screening, and counseling meant?  Is is covered?  What is screening?  Is it running tests?

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