LAS VEGAS (KTNV) — Most of us don't play detective with our medical bills.
We're told how much we owe and assume it's the right amount. However, we all may want to think twice about that. When one Las Vegas man paid close attention to his doctor bills, he noticed he was overcharged three times.
He reached out to ask Darcy, What's the Deal?
WATCH | Las Vegas retiree catches medical deductible overcharges
Roy Heaton loves a fishing expedition. He spends much of his retirement casting lines at Lake Mead. Recently, instead of catching bass, he caught payment problems on his medical bills and he doesn't want others to be in the same boat he found himself in after a January 2024 visit to Desert Radiology.
"I had an x-ray done and they charged me $138.05 and I said okay, I'll pay it," Heaton said. "Again, you think medical or doctors, they know what they're doing."
However, when he got home, he double-checked his insurance benefits and realized he shouldn't have paid anything.
"I called Desert Radiology and said hey, it's supposed to be zero and they said okay, you're right."
Heaton waited about three months before receiving a refund check. Over the past year, he says it happened twice more.
"We jump to January of this year and I had to have a PET scan done. This time, for whatever reason, I thought about it and I called Aetna prior and said how much is my deductible on a PET scan. They said $200," Heaton said. "So I went into Desert Radiology and she said okay, it'd be $477. I said where do you get that number? I said I called Aetna and they said $200. She got on the phone with somebody and then said okay, tell you what. You pay your $200 and then, if it is anymore, we will bill you."
A few weeks after that, Heaton said he went in for an x-ray on his knee.
"Same thing. I made sure it's a zero deductible on the x-ray. I called Aetna. Then, I went to Desert Radiology and he said well, it's $51. I said I called Aetna and it's zero. She got on the phone again and called. Okay. You know, we'll bill you if you're wrong," Heaton said. "That is what made me contact you. If they're telling people the wrong deductible amount, how many times do they do it? How often does this happen?"
Unsurprisingly, we learned billing mistakes are common.
According to the American Medical Association, industry estimates indicate anywhere from 30% to 80% of all medical bills have some sort of error. A Consumer Reports survey also found one in five Americans have spotted medical bill mistakes over the past year.
We asked Desert Radiology what's the deal with Heaton's overcharges. They declined an on-camera interview but sent us the following statement, deflecting responsibility:
"Desert Radiology has proudly served the Southern Nevada community for more than 60 years and remains committed to transparent and accurate billing practices. Patient deductibles are determined solely by each patient’s health insurance plan. The portion applied to a patient’s out-of-pocket costs is based on information provided by their insurance plan carrier when the claim for our service is processed. Desert Radiology does not set or influence deductible amounts.
We encourage patients who have questions about their bill to reach out to our billing team, who will be happy to help. Contact information is available on our website at www.desertrad.com."
"I'd like to know where they get their numbers in, who puts those numbers into the computer because it's [a] very obvious explanation of benefits," Heaton said. "If they called Aetna, they would have told them the correct amount. Aetna knows."
We went to Aetna, Heaton's insurance company, for more answers about how deductible amounts are shared with providers.
"Well, they also get statement — like an explanation of benefits — to tell them. And normally, provider offices will get that, put it in their system, and we'll bill the member correctly," said Art Kummer, Aetna's Chief Medicare Officer for California & the Western Territories. "We'll say you owe $10 and here is the discount we provided the insurance company."
The bottom line in this case is that Heaton is the one who caught the overcharge and worked to set it straight.
So what should you do if you have questions about how much you should pay at the doctor's office?
Aetna says don't pay until you get your explanation of benefits and contact your insurance company with any questions.
"Consumers should wait until the claim is processed and the insurance company has sent them something saying this is how much I owe. And then, pay that amount," Kummer said. "You don't just want to pay bill charges. If it's a network provider, there's going to be a discount and you can't know the discount until they pay the claim."
Health Insurance FAQs
What is the difference between a deductible and billed charges?
"A deductible is what you have to pay before your co-insurance would start coverage. So you might say I have a deductible of $400. You'd have to pay $400. Then your plan is met," Kummer said. "What's important to realize is that the $400 isn't the bill charges. The $400 is the contracted rate that a participating provider has."
What is an explanation of benefits?
"What I would tell consumers about what you owe is every time we get a claim, we send out to the member an explanation of benefits. We call it an EOB. That explanation of benefits has three big numbers on it. It'll say what you have to pay as a consumer, what the health plan paid, and then the discount the health plan negotiated with the provider," Kummer said. "For the EOB, it will say in a big box, this is your share and that's all you really need to pay."
What do deductibles apply to, specifically for Medicare plans?
"The trend in Medicare Advantage plans is the deductible usually doesn't apply to physician office visits. It really only applies to the rare surgery facility, hospital, those kinds of items."
What should I do if I feel like I've been overcharged?
"The EOB is really the key thing to look at ... You really want to take your EOB and compare it to what your doctor billed you and you should only pay what the EOB says is your share for that particular date of service," Kummer said. "If the member just calls the provider and says hey, my EOB is this. I paid you this. Can you refund me the money? And if the provider isn't cooperative, if you don't feel comfortable calling the provider, you can call your health insurance company who can intervene on your behalf."
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