Check your medical bills— here’s how I got a $1,500 refund

by Jordan Stone , VP of Engineering at Paytient

When you swipe your card at the grocery store, you trust the total on the cash register is correct. We place a similar faith in most companies we interact with, assuming they are correctly handling the responsibilities we've entrusted to them—especially when it comes to adding up the bill. A few weeks ago, I had a sobering reminder that when it comes to medical billing, this trust can be misplaced.

Healthcare is complicated, and how we pay for it is often even more so. To understand how billing errors happen, you need a peek behind the curtain. 

How a medical bill gets made

After you visit a doctor, a complex dance begins between your healthcare provider and your insurance company. First, the provider sends a claim to your insurance company. It includes a list of all the services and procedures they performed. Your insurer evaluates the claim to make sure it’s valid, checking that you had coverage on the date of service, whether or not the provider was in-network, and if the services on the claim are allowed to be covered by the plan. 

Once these details have been confirmed, the plan will look at the pre-negotiated rate for those services, which is the price. To determine how much the plan will pay versus how much is the patient’s responsibility (aka your out of pocket cost), they will look at the cost-sharing terms of your plan (any deductible or copays you may owe up to your out of pocket maximum). Taking into account anything you’ve already spent this year, the plan will determine how much they’ll pay and what you owe.

This back-and-forth, known as adjudication, can take weeks or even months, with adjustments and reversals passing between the two parties. At the end of this process, the plan sends you an EOB, or Explanation of Benefits, to show you which services were covered, the total price, and how it will be split between you and the insurance company.  This is the document you get in the mail that usually says, “This is NOT a Bill.”

At some point, the provider sends you a bill for the remaining balance they believe you owe. We trust this final number is accurate. But these systems are fallible, and as I discovered, the responsibility falls on you, the patient, to verify your bills and advocate for corrections.

Here’s how I found out the importance of checking your medical bills

My journey started earlier this year when I received a medical bill for just under $900. It was the beginning of the year, so I assumed it was my responsibility toward my annual deductible and paid it. A few months later, another bill arrived for over $600. By the end of summer, a third bill for more than $1,000 landed in my mailbox. I was sure I had met my deductible by then, so why were these amounts still so high?

Because I had paid every bill with my Paytient card, all of my healthcare spending was organized in one place within the app. This made investigating easy. I pulled up my transaction history and cross-referenced each payment with the EOB my insurer had sent after each visit. 

What I found was shocking. For the first two services, my EOBs clearly showed that my insurance company had paid 100% of the negotiated rate. The provider had billed me anyway, and I had paid for services that were already covered and paid in full by my plan. Because the provider was doubly paid, my payments didn't even count toward my deductible.

I immediately called the provider’s billing department. After a review, they confirmed their mistake. For the services in both January and June, they had marked my payments as overpayments and owed me a reimbursement of more than $1,500.

What’s more, they admitted that had I not called to inquire about the discrepancy, no refund would have been automatically issued. The money would have simply been lost unless the provider happened to conduct a future internal audit. While the experience was frustrating, I was grateful that Paytient had allowed me to create an interest-free payment plan for those initial charges, which had significantly reduced the financial stress at the time.

How to be your own medical billing advocate

This experience taught me a valuable lesson: at the end of the day, you are your own best advocate. While medical billing is confusing, it’s critical to take the time to understand what you’re being charged for and verify that the amounts are correct.

You don’t have to be a billing expert, but you do have to be vigilant. Here’s how:

1. Always Wait for Your EOB. Never pay a provider’s bill until you receive the Explanation of Benefits from your insurer.
2. Compare the Bill and the EOB. The "Patient Responsibility" amount on your EOB should match the amount on the bill from your doctor or hospital.
3. Question Everything. If the numbers don’t line up, call your provider’s billing office. Ask them to walk you through the charges and explain any discrepancies.

While this may seem overwhelming, it’s actually quite simple once you know what to look for. And once you know what to look for, you can protect yourself from costly errors and take control of your healthcare costs.

*Note: I’m an engineer by trade, not a benefits professional. This information is shared to be educational but should not be taken as benefits advice. If you have questions about this, always reach out to your insurance company or a benefits expert like your HR team or a licensed insurance broker.