Everybody has bad experiences in healthcare. Though I haven’t (yet, thankfully) dealt with the nightmare of facing bankruptcy or being denied urgent treatment, I do have my own stories of clear breaks in the healthcare ecosystem. This category is my attempt to share some of them on an increasingly-sparsely-populated family blog.

Today’s story culminates with the following message I sent to some fellow HL7 nerds:

Who’s at fault when a health system doesn’t properly update your address, doesn’t tell you you have a balance when you check in for subsequent visits, doesn’t show anything about said balance in the billing area of MyChart, and then sends you to collections when the bills they’ve sent to a 5-year-out-of-date address go unpaid?

Read on to find out how it happened, why it’s extra-infuriating to a nerd like myself, and what you can do to prevent it from happening to you!

“Have there been any changes recently?”

You know how every time you check in for an appointment, the front desk asks you to verify a bunch of information, including your address? That’s not so they send you get-well cards or promotional material (well, maybe a bit of the latter); it’s so they know where to send the bill to get your money after insurance has dictated how much the provider is allowed to charge in your network and how much you owe after deductibles & co-insurance is calculated.

I can vouch that the folks at our clinic do a fantastic job of keeping this information up-to-date. I have 5 daughters, and answer this question every time. The problem is that our clinic and the hospital are apparently on two different systems, though they share the same name. Complicating the matter is a recent acquisition / renaming / rebranding – I don’t know exactly what happened, but I’ve seen 3 different names for our health system since moving to town 6 years ago. However, the daughter in question has never been to the hospital, so that shouldn’t matter…right?

Labs, Clinics, and Hospitals – Oh My!

Apparently in our health system, labs done in the clinic are actually sent to the local hospital for processing. This is not an outpatient clinic attached to a hospital facility’s physical building. They physically transport the blood to a lab at the hospital across town for processing. At least – that’s the impression I get from the billing codes on our insurance site. Maybe they do them in-house and just bill under the hospital? In any case – when my daughter has labs done as part of a well-child visit, I can expect to see a claim for the office visit (clinic), the blood collection itself (also clinic…maybe?), and the actual tests themselves (might be from the clinic; might be from the hospital). How do I know that’s what I can expect?

Spreadsheets For the Win!

Whether it’s my analytical/logical brain, Dad$ense about money, or just a love affair with numbers and spreadsheets (or all of the above), I have maintained a massive multi-sheet document with every charge, provider, claim, discount, co-pay, and other expense since my “adult” life began post-college. I know what the provider started to bill, what the insurance said was allowed/discounted/etc, what the co-pay/co-insurance was, and finally, the date on which I paid the bill along with confirmation number. This has helped me convince providers that, no, I don’t owe them money because I’ve met my deductible; prevented me from double-paying bills that have already been paid; or in this case – verify that a collections letter was actually legit. (It also helps me compare PPO & HDHP health plans, but that’s a different article)

On the date of service in question (July, 2022), my daughter went in for a routine physical with an additional question related to a potential dietary reaction. For the unaware: while well-child/physical/preventative visits are usually covered 100% by insurance, as soon as you ask about any other symptoms, it becomes a regular office visit. And though our insurance covers labs done as part of preventative visits 100%, this turned into a regular office visit (actually there were 2 codes: one for the preventative visit and one for the office visit), and all the labs were associated with the office visit, so we were on the hook for them. To complicate the matter even more, she had an X-ray along with this visit. So for the date in question, my super-spreadsheet has :

• Preventative Visit ($0 copay)
• X-ray (Co-insurance; on clinic claim)
• Outpatient Visit (Co-insurance; on clinic claim)
• X-ray (Co-insurance; on radiologist’s claim)
• 4 different “LAB” – related charges, some zeroed out; some with co-insurance; all on a claim from the local hospital (note – these were all normal labs that would be done as part of the physical, like a CBC and CMP; the only “new” thing was the X-ray)

A month after his happened, I received and paid a significant bill which included this date of service. For the non-nerds just paying whatever bill comes along, this would have seemed to cover the visit, especially if the non-nerd looked at the dates of service on the bill and remembered taking their daughter to the clinic on that day. But using my spreadsheet, I did know that, while the bill seemed high – certainly high enough to cover the co-insurances for all the labs, it actually only covered the X-ray and Office Visit charges. The rest was for earlier urgent care visits. So I left these rows on my spreadsheet as “unpaid”, thinking they’d either send me a bill later or (as I hoped) realize these charges were part of the physical and should have been covered 100%.

By the end of the year, these charges were buried with hundreds of other charges in the year, most of which had a corresponding value in the “Date I paid” column. Believe it or not, having rows on this sheet – that insurance says I owe something on, but for which I never receive a bill – happens a few times a year. I don’t maintain this document to make sure everybody gets paid; I maintain it to make sure I don’t get over-charged on something I shouldn’t owe.

Moreover, since our system uses Epic, and I can sign into MyChart for all my kids – I could see that the bill I just paid covered the entire balance listed for the visit. I’d also been to the clinic subsequently and not been told about an outstanding balance. Great! I’m off the hook for those charges – or so I thought.

Fast-forward more than a year later, and I receive an ominous collections notice in the mail. A bill of $795 had had $686.78 already paid, and I still owed $108.22 and had better pay up! What’s weird is that I never pay “part” of a bill. We even auto-pay our credit cards’ full balance very month. Fortunately, with my massive spreadsheet, I was eventually able to figure out where their numbers came from – even though none of them matched a specific claim directly. The “paid” amount was a combination of my insurance network’s “discount” as well as what insurance actually paid, and the totals were only the lab portion from that date of service.

Now the question is…. why did I never receive a bill for this??

Billing and Records Phone Tag

I start by calling the clinic – you know – the only place my daughter has ever been seen? This is where I learn that the lab billing happens within the hospital’s system, and I need to contact them. Apparently, this is also why the charges don’t show up on MyChart. So onto phone call #2. I speak to billing at the hospital, confirm the claim # on the collections letter matches my daughter’s account, verify the outstanding balance, and pay it over the phone (I’m assured at this point that the collections process will be ended; the jury’s still out on that). As to why I never received a bill? I’m told that it was sent to an old address… mine from two moves and five years ago, and I’d have to call medical records to get that updated.

So to clarify: our local system, which is integrated enough to transport physical blood between sites and present the results of tests back to the ordering physician (and us, though MyChart), cannot keep addresses in sync? But wait – if my daughter has never been to the hospital, how does the hospital have our old address in the first place? At some point in history (possibly pre-rebranding), the clinic must have shared with them our home address.

My final call with medical records shed a bit more light on things – but not completely. They were able to access both the clinic and hospital systems, verify that several of our kids had old addresses, and then one by one, we opened each chart in both systems and verified that I was listed as their guarantor (the one who ultimately pays the bills) with a proper address for each of us. I reiterated how important this was to me….because this is the second time this entire process has happened!

Almost one year ago to this day, we got a notice from collections for a different daughter about a similar issue. Practically the same situation, too, but with slightly different outcomes. She had SEVEN different lab tests done as part of a physical the previous year, but apparently six of them fell under the preventative bucket and were covered at 100%. The seventh, languished in old-address obscurity until sent to collections. That time, however, I apparently corrected only her address, and not the address of everyone else in my family.

How to prevent this from happening again?

I’ll try to not be too snarky here – but the general answer is: not much. I work in healthcare data interoperability, and I’m a huge nerd with a massive tracking spreadsheet, and I still missed this. I’m not sure there’s a great global solution (like single-payer-healthcare, a national patient database, or even more stringent regulations on already-complex medical billing processes). Each system is going to be different, and as consumers, we have some responsibility to actually pay for the services we receive. It would be great if health systems would keep addresses up-to-date and in-sync with themselves (and/or apply the same magic used by collections agencies to figure out where to send the threatening letters), but barring that, there are a couple of steps I could have done differently and others could do proactively.

At a minimum, when you move – make sure your address is updated everywhere – in particular for any provider that has sent you a bill in the past (though this is tricky, too – since every bill I’ve received from this system, whether from the clinic or hospital, looks the same). If you know your health organization has recently changed names, maybe ask about whether they have old systems where your address should be updated in as well. And if you have kids / other dependents – make sure the address is updated for all of them.

While not everyone needs to keep a multi-year spreadsheet with detailed charges and payments, you might benefit from checking in once-in-awhile with your insurance, seeing what they think the patient portion is, and then holding on to that information until you pay a bill. For awhile, I was receiving regular “Explanation of Benefit” letters from my insurance with big THIS IS NOT A BILL alerts all over it. I threw these away because I had that information online, but this could be another source of alert that you probably should expect a bill from your provider in the future. Do I think you should call up every provider who hasn’t sent you a bill after thee months and say “hey, you sure you don’t want me to send you some money?” No – that still seems like a bad idea. Then again, so does sending someone to collections who always pays every bill they receive on-time.