Nationwide Medicare billing errors a multi-billion dollar problem

ORLANDO, Fla. — A lifetime of working on computers and playing the drums has left Central Florida resident Tony Portella with pain in his wrist. After months of discomfort, he decided to go have his wrist checked out at a local walk-in clinic.

“I went into the examination room and the doctor came in and he asked what he could do for me. I told him my wrist hurt and he said I don’t know what’s wrong with it and that I needed to go see a specialist, that was it,” Portella said.

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The GuideWell clinic didn’t perform an X-ray or MRI, but did send Portella home with a wrist brace. Days later the bill for the visit came, for more than $3,500.

“Something is not right,” Portella said. “I’m on Medicare, but to me it doesn’t matter who is paying for it, something was not right.”

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Portella reached out to the clinic for an explanation, but did not get a resolution. 9 Investigates also contacted the company with a representative indicating it appears to be a billing error, writing in part, “for every procedure and service we provide to our patients, there is a code associated with it that we use when billing health insurance companies,” adding that, “on rare occasions, some services are coded incorrectly and the wrong amount is billed.”

GuideWell said it would contact Portella and work with staff to make sure a similar error did not happen in the future.

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While Portella’s case is unique to him, nationwide errors when it comes to Medicare are a multi-billion dollar problem.

“What is troubling is that most insurers, including Medicare, will not go through the trouble of challenging a bill,” said Caitlin Donovan of the National Patient Advocate Foundation. “We estimate that about half of all medical bills have mistakes on them, and those mistakes cost patients one way or another.”

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In a 2018 report, the Council on Medicare Integrity found that the Centers for Medicare and Medicaid Services (CMS) reduced its error rate from 9.5% to 8.1% but that, “this still resulted in a $31.6 billion loss to Medicare,” adding that, “over the past six years, Medicare has lost more than $230 billion to improper payments – preventable billing mistakes caused by simple coding errors, double billing, up-coding and insufficient documentation.”

“It is always worth a second look at your bill,” says Donovan.

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