Investigating My Medical Billing Nightmare

Alright, my rant about my struggles with medical billing is done. I’m personally in the clear, but now I’m really curious to know what happened, especially with the most recent billing mishap. In addition to figuring out what happened to my case, I’d like to see if perhaps there’s anything I can do to make sure it doesn’t happen to somebody else.

To get you up to speed on where I left off in my last rant:

• I’ve had a few medical bills get screwed up, especially with out-of-network providers. I have insurance with Anthem through my employer.
• In one particularly problematic case (aka “Screw-up #3” from the rant), I’ve been in a bit of a dispute between Anthem, UCSF SFGH Medical Group, and Transworld Systems Incorporated (a debt collection agency), to sort through a medical bill with a balance due of $789, from date of service October 6, 2016.
• UCSF SFGH Medical Group insists that they submitted my claim information to Anthem on October 31, 2016.
• Anthem insists that they have no record of my claim being submitted or processed in any way, not even as a denial.
• After over a year of me chasing this down, UCSF SFGH Medical Group has reviewed my case and will be dropping the balance, as of October 27, 2017. Nothing due for me anymore.

Background Lessons in How to Adult: Claims and DCNs

In the last year (and especially in the last week) I’ve picked up on a few new bits of information about medical billing that I never learned in school (but I did learn how to write in cursive so there’s that). Here’s some definitions for you in case you’re not familiar with these terms.

MRW I call someone to talk about my billing situation and have no idea how these things work

A claim is a request for payment that goes to your insurance.

• There are multiple ways for a claim to be reported to your insurance provider, but one way is through a CMS-1500 form, which looks like this.
• CMS-1500 forms are produced based on standards from National Uniform Claim Committee.
• There are multiple versions of the form, with v0212 being the current, and v0805 being its predecessor.

A Document Control Number (DCN) is a number which can be used to either identify a claim that’s being processed, OR to identify a particular specific document or image used in correspondence.

• A claim itself will have a DCN, as will any letter that is sent to/from an insurance agency about a particular claim.
• A DCN typically has a year and date encoded in it, where the date is represented as a Julian number — i.e. the number of days since January 1 of that year.
• For DCNs of insurance claims, the Julian date is intended to represent the date at which the claim was received by the insurance provider.

Investigating the DCN I Had

As a part of my conversation with UCSF SFGH Medical Group on October 27, 2017, I was provided a Document Control Number for the rejection notice that came from Anthem.

The DCN began with 2016316, where 316 shows the Julian date of November 11 (2016 was a leap year). This isn’t the same date as the October 31, 2016 I heard previously as the date of claim submission, which I’m guessing is because this DCN is for the denial letter that was sent, and not a number for an actual claim.

After my conversation with UCSF SFGH Medical Group on October 27, 2017, I called Anthem and got Christina (sp?). I tried to be as brief as possible as I explain the situation, and give some context as to why I wanted more information about a particular DCN.

How I imagine every Anthem agent feels after 30 seconds into my dialogue responding to “How can I help you?”

She looks up the DCN, and there it is — the rejection notice for the claim that was submitted by UCSF SFGH Medical Group, which Anthem has previously been unable to find.

So, Anthem did get my claim. They’ve had it this whole time.

Quite curious about where this communication breakdown occurred, I asked some more questions to Christina.

Based on conversations with her and some of my own independent research, here’s the information I have so far:

• The form submission to Anthem was an electronic one, so nothing is handwritten. It’s all digital and handled by the machines.
• If Anthem receives a claim and there’s an error on it, Anthem will return that error to the originating group.
• The claim submitted by UCSF SFGH Medical Group error’d out when being processed by Anthem. The error message produced by Anthem’s systems is: “Only qualifier 431 or 484 are valid for box 14. Box 14 contains date qualifiers which are blank, invalid, or illegible.”
• In Anthem’s systems, claims are only going to show up in my online dashboard when they are accepted for processing. If there’s a coding or billing error which prevents it from advancing to that stage, it will simply be kicked back to the provider (and that’s what happened here).
• The claim form submitted UCSF SFGH Medical Group to Anthem did not have my SSN, only my Anthem Member ID.
• The DCN for the rejection notice sent by Anthem to UCSF SFGH Medical Group was associated to me in Anthem’s systems using my SSN, and not by my Member ID. This would explain why support agents at Anthem have previously reported to have no record of this interaction when I’ve called them.

So, something in Anthem’s systems used my Member ID from the CMS-1500 form submitted by UCSF SFGH Medical Group electronically, to tie that claim submission attempt back to my SSN. It then generated a rejection letter, and associated that rejection letter to a human (me) using the SSN instead of Member ID. This is problematic for a couple of reasons, one being that this means Anthem support agents can’t look up this letter when I call, even though it’s about me.

Christina referred to this system as “Import Server.”

I’m on to you, “Import Server…”

Additionally, there seems to be some issue with the intended use of Box 14 in CMS-1500 between UCSF SFGH Medical Group’s systems and Anthem’s systems. According to this site, Box 14 is meant to only be used for qualifier 431 or 484, but was used for 439 (the code for “Accident”). I’m not sure if it’s against the standards to use Box 14 to specify the date of an accident if Box 15 is blank, but Anthem definitely seems to consider this a strict rule, and therefore considered this claim invalid.

Christina has put a note for my employer’s Anthem representative to get in touch with me early next week, where hopefully I’ll be given an opportunity to find folks to investigate this further.