I’ve been seeing the same PCP for at least the 2+ years. Every time I finish an office visit I ask the office staff how much is due. I would always pay on site for what they said was due which was about $44. Today was a different experience. Today they said the total for the visit was considerably higher than all my prior visits at $148(my insurance hasn’t changed in 2 years). I asked them to confirm and they said it was correct after checking with the office manager. I asked some more questions which led to the office staff involving the office manager who then told me my balance was actually greater by $80 than what they had just told me seconds ago and was actually $219. I asked why that was the case and she said it was because the visit was actually a “class 4” visit (99214) instead of a “class 3” (99213) visit which is where the different number came from. I asked what the difference in classification was and she said it was up to the doctors description. That didn’t feel like a very legitimate answer so I pushed a bit more and asked if it was just an arbitrary decision made by the doctor or if there are descriptions that that differentiate these level of visits. I cut to the chase and asked for those descriptions in writing to which she Googled the difference between the class 3 and class 4 visits. Of course my visit clearly fit into class 3 but when I asked her to ask the doctor to reconsider his classification based on the written descriptions from google the office manager provided, they refused because the doctors said if they did it for me they would have to do it for everyone. Around this time, the office manager told me that not only did I owe the $219 for todays visit, that the office and billing company had failed to do their jobs correctly and I actually had a several year balance of well over $800. I was shocked by this and explained I had received zero notice of this balance. The office manager even admit that it was their fault.
I share this story because I want to know what options I have. Logic would tell me that if they made the billing mistake that at this point the “bad business” would have already been written off. Even if that isn’t the case, I have received zero notices of this balance and it hasn’t effected my credit at this point which means they haven’t been looking for the money either. Do they have a right, all these years later, to expect me to pay this balance even though they admit it was their fault to begin with? If so, are there any options I have? I wonder if I can issue a complaint to the medical board or some other entity?
I also have a voice recording of the office manager admitting fault
Your first step is to review the Explanation of Benefits (EOB) provided by your insurance. You can find it on your insurance portal, and it will show how each claim was processed.
The amounts due on each claim should match what the office is charging you, assuming the provider is in-network.
It’s odd they didn’t mention a balance during your visits. If they knew about it and let it accumulate without telling you, something is off with how they operate.
Level 3 vs. level 4 visits can be confusing, but even a visit that seems simple can be coded as level 4. What were these visits for? Was it for medication management? It’s hard to assess the accuracy of the coding without knowing more details.
How far back do these visits go, and where are you located? States have different laws about billing practices. Once you get your EOBs, check the dates they were processed.
Yes, the key to understanding your balance is to review the EOBs. For in-network providers, the insurance company determines the patient’s responsibility for each visit. If the insurance indicates you owe a certain amount, then that is what you owe.
Disputing whether a visit should be coded as 99213 or 99214 probably isn’t worth the effort. I would be surprised if the chart note didn’t document the time spent on the encounter, which is the basis for a 99214 code. Remember that the rules for Evaluation and Management (E&M) visits changed in 2024. If the total time spent on your chart that day was 30 minutes (including face-to-face time, writing prescriptions, researching, etc.), it qualifies for a 99214.
I completely agree. Check your old EOBs and compare the amounts you paid. For example, if you paid $44 but the EOB states you owe $50, then you would owe them $6 for that visit.
Also, double-check that they are in-network for these visits. Providers can leave a network without notifying you. While they shouldn’t lie about it and should ideally inform you on the day of your appointment, they aren’t required to do so. If they are out of network, they can balance bill you, but if they are in-network, the amount on the EOB is all you owe. If they disagree with that amount, they can file an appeal, just as you can if you disagree with an EOB.
I also recommend checking your state laws regarding how long a medical provider has to send the first bill. Some states have specific time limits for issuing an initial bill.
I really appreciate all this. This is incredibly helpful and encouraging. For reference, I am in Texas. The visits go back to at least 2022 and probably 2021. They are in network. I was there to discuss a change in medication and was with the doctor for less than 10 minutes. The only examination done was to hear my breathing and get my vitals. I am curious, is there any legal or ethical issues with their admitted billing errors?
You’ll need to check when the visits were billed to insurance, how much you actually owe, and how much you’ve paid so far.
A change in medication can definitely trigger a 99214, depending on the specifics. There’s no indication of fraudulent coding in this case.
Not really, maybe. I don’t have enough details. If you owe the bill, then you owe it. Have they mentioned whether statements have been sent to you? If so, how were they sent?
Patients often claim they never received a bill, but we can confirm it was sent to their email on a specific date and time—and suddenly, they find it!
The only thing that makes me uneasy is if they repeatedly saw a patient without collecting any payment at check-in when there was a balance on the account. But that assumes everything processed smoothly with insurance.
It’s possible that insurance just took longer to process these claims, which is why it’s important to review your EOBs.
The issue though is the mistake was with the office. They were charging me less than 25% of what they should have been charging me. They didn’t have to send anything to insurance other than just documenting that it is applied against the deductible. The office manager admitted they made that mistake, the billing problems didn’t have anything to do with insurance.
Your understanding of this is not quite right. The office sends claims to your insurance company, which then decides how to process them. After that, the office bills you based on the insurance company’s decision.
Do you like this provider? Would you like to continue seeing them?
Have you checked your EOBs? The billing issues may be related to insurance.
I’m here to help you sort this out, so you really need to review your EOBs.
Mistakes can happen, and upcoding is a common type of fraud. However, without any additional information, I’m going to assume there’s no error or malicious intent. A doctor and their professional billing staff are likely more knowledgeable about appropriate coding than either a random Redditor or even someone like me who works on the insurance side.
As you move forward, remember to stick to the scheduled agenda during your visits. Don’t let the conversation drift into other topics, as that can lead to additional billing items. Sometimes those extra charges are warranted, but often they are not.
I recommend obtaining the explanation of benefits (EOB) to understand why the expense for “class 3 and class 4” is significantly higher. As a biller, I haven’t encountered those terms before. The codes 99213 and 99214 refer to CPT codes, indicating follow-up visits that are typically time-based: 99213 is for visits up to 30 minutes, while 99214 is for visits up to 45 minutes.
How these visits are recorded can vary depending on your insurance, as each insurer has different billing guidelines.