Patient files complaint over medical billing nightmare he says likely impacts thousands of Coloradans

A Douglas County man has discovered a medical billing issue that could impact thousands of Coloradans. It involves one of the state's biggest insurers, leading providers, and newest insurance plans - the Colorado Option.

This year, every insurer had to start offering the standardized benefit plan that was designed by the state to save people money on health care.

Robert Schwartz is one of 35,000 Coloradans who signed up for the Colorado Option. He says he went with the plan offered by Anthem Blue Cross Blue Shield because his primary care doctor is in-network with Anthem. The plan includes full coverage for all primary care visits with an in-network physician, meaning there are no co-pays or deductibles.

So when Schwartz received a $136 bill from University of Colorado Medicine for a primary care visit in February, he figured it was an isolated mistake. Anthem blamed CU Medicine for the error, saying it used a code for an "outpatient hospital visit" rather than an "office visit," even though the insurer called it an "office visit" on Schwartz's Explanation of Benefits form.

The issue grew more complicated when Schwartz called CU Medicine, "And they informed me that there is no such thing as an office visit, that visits are classified as outpatient, inpatient, or consultations. I figured, okay, new plan this is just an issue of terminology they've got to work through."  

A retired human resources executive, Schwartz filed a complaint with the Colorado Division of Insurance.

"It is not a complicated fix. It's getting the right people in the room to say let's make this happen," he says. "At this point, because we're in June, it also means sweeping back to January first to see how many people were processed incorrectly and fix those problems." 

He assumed that fix would happen until he got another bill, "May 10th I had another doctor's appointment, same exact thing." 

He's now received three bills for three primary care visits, "All three of the claims are exactly the same diagnostic code."

While Anthem says the code is for an outpatient hospital visit.  

The Division of Insurance says Schwartz is the only one who's complained about the issue.

He says, if it's happened to him three times in four months, it's likely happened to others, "I hope I'm the only one. I would love to find out through this that they made three mistakes in the state and Rob Schwartz is the only one that those three mistakes happened to. That would be great. I don't believe it though."  

In all, Schwartz says he's been billed for about $500 in primary care that Anthem should have covered under the Colorado Option. But he says, if this is happening to other Coloradans too, it could add up to millions of dollars in overcharges.

Anthem and CU Medicine say they are looking into it.

Emily Snooks, Director of Public Relations for Anthem Blue Cross and Blue Shield, shared the following statement after CBS Colorado's report first aired in a newscast:

"We depend on providers to submit accurate information regarding how and where medical care is delivered. In the claims that we were asked to review, we can confirm that the claims were submitted to us by the provider with "outpatient hospital" listed as the site of service. As such, the claims were processed as outpatient hospital claims and paid according to the benefits in the member's plan."

The following statement from Michelle Malgesini, University of Colorado Medicine Associate Director of Marketing, also was shared afterwards:

"To protect patient privacy, University of Colorado Medicine (CU Medicine) does not comment publicly on specific patient matters.

CU Medicine follows the national medical billing guidelines that are set by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), which require patient visits to be billed based on the classification for the facility where the patient was seen. When services are provided at a hospital-based clinic, these guidelines require that the visit must be billed as an outpatient hospital visit. The designation of a hospital-based clinic is determined by a hospital system. In some cases, benefits under a patient's insurance plan depend on that designation. CU Medicine encourages patients who have questions regarding charges to contact their health insurance company directly."