For most of us who have health insurance (employer group, individual coverage, VA, Medicaid or Medicare), chances are we never see the bill from the doctor or hospital. It is sent directly to the insurer for payment. Isn't that nice!

Or is it? About six weeks later we may get a print-out from the insurer stating the bill amount, what the insurer paid, and what we as the insured may still owe. A few weeks later, a bill from the doctor or the hospital arrives with a very short “pay by” date. This includes any deductibles, co-pays and, more importantly, amounts in excess of what the insurer covered. Too often it's quite a bit. For what?

The bill never says and the statement from the insurer is likely to show only codes with some vague references. You saw one doctor for perhaps 15 minutes, but you get bills from six different entities all charging for that same short visit. That's how the game is played – you don't see what is being charged for your care, and the service providers (physicians, clinicians, X-rays, pharmacies, therapists, pathologists and specialists) each feed off that same insurance. Did you actually receive the care for which your insurer was billed?

The role of the adjuster

Several evening news magazine programs have run features on how medical providers through the insurers are ripping off the system. It happens in other types of insurance as well: bodily injury liability, medical pay or workers comp, but there is a difference. Supposedly, somebody is looking at all of those medical bills and thinking, “Hey, how does this relate to a broken arm?” How many X-rays of that arm were needed, and was a MRI or CAT scan really necessary? We call it “medical bill auditing,” but apparently the folks in the healthcare/medical insurance business never heard of it.