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The Medical Bill Mystery
HughPickens.com writes: Elisabeth Rosenthal writes in the NY Times that she has spent the past six months trying to figure out a medical bill for $225 that includes "Test codes: 105, 127, 164, to name a few. CPT codes: 87481, 87491, 87798 and others" and she really doesn't want to pay it until she understands what it's for. "At first, I left messages on the lab's billing office voice mail asking for an explanation. A few months ago, when someone finally called back, she said she could not tell me what the codes were for because that would violate patient privacy. After I pointed out that I was the patient in question, she said, politely: 'I'm sorry, this is what I'm told, and I don't want to lose my job.'" Bills variously use CPT, HCPCS or ICD-9 codes. Some have abbreviations and scientific terms that you need a medical dictionary or a graduate degree to comprehend. Some have no information at all. A Seattle resident received a $45,000 hospital bill with the explanation "miscellaneous."
So what's the problem? "Medical bills and explanation of benefits are undecipherable and incomprehensible even for experts to understand, and the law is very forgiving about that," says Mark Hall. "We've not seen a lot of pressure to standardize medical billing, but there's certainly a need." Hospitals and medical clinics say that detailed bills are simply too complicated for patients and that they provide the information required by insurers. But with rising copays and deductibles, patients are shouldering an increasing burden. One recent study found that up to 90 percent of hospital bills contain errors. An audit by Equifax found that hospital bills totaling more than $10,000 contained an average error of $1,300. "There are no industry standards with regards to what information a patient should receive regarding their bill," says Cyndee Weston, executive director of the American Medical Billing Association. "The software industry has pretty much decided what information patients should receive, and to my knowledge, they have not had any stakeholder input. That would certainly be a worthwhile project for our industry."
So what's the problem? "Medical bills and explanation of benefits are undecipherable and incomprehensible even for experts to understand, and the law is very forgiving about that," says Mark Hall. "We've not seen a lot of pressure to standardize medical billing, but there's certainly a need." Hospitals and medical clinics say that detailed bills are simply too complicated for patients and that they provide the information required by insurers. But with rising copays and deductibles, patients are shouldering an increasing burden. One recent study found that up to 90 percent of hospital bills contain errors. An audit by Equifax found that hospital bills totaling more than $10,000 contained an average error of $1,300. "There are no industry standards with regards to what information a patient should receive regarding their bill," says Cyndee Weston, executive director of the American Medical Billing Association. "The software industry has pretty much decided what information patients should receive, and to my knowledge, they have not had any stakeholder input. That would certainly be a worthwhile project for our industry."
Now that we live in a world where healthcare is primarily self pay for the first few thousand, we need to take this into our own hands. Ask what a procedure costs before it's done and what other options are there.
Recently I had a bad sore throat (for like 2 weeks and it was getting worse). I go to the doctor and he wants to run a strep test. I ask him what we will do if it says I have strep. He replies that I would get antibiotics. I ask him what he will do if says I do not have strep. He says it's most likely still bacterial and he would give me antibiotics.
So I ask him why he wants to waste my money. After a talk about how my new improved insurance works we now talk about the cost vs results of my medical care.
I then shopped around for the prescription. I found that by calling places and telling them I did not have insurance I found a cheaper rate than buying it with my insurance! Medical care has now turned into a system similar to buying a car.
First and foremost, medical billing is a nightmare.
Second, it's actually pretty well standardized. There can still be some ambiguities, but it's not as obtuse as it sounds.
Any test, procedure or office visit is considered a "procedure" under the billing rules and has a CPT procedure code. These are easy to look up on the web. I had no trouble finding the three mentioned in the post doing a simple Google search. Every "procedure" must have an associated diagnosis code to justify the use of that procedure. Again, this is set up to allow insurance companies to deny care based on arbitrary minutia. On rare occasion, more than one lab or procedure can have the same CPT code. In those cases, you have to look a little more closely at the description.
Let's look at the example give.
CPT 87481 Bacterial vaginosis swap
CPT 87491 Gonorrhea/chlamydia test
CPT 87791 infectious agent by DNA amplification
A reasonable guess here is that these are lab tests from a trip to the gynecologist's office. The CPT 87791 is a little vague, and represents any test performed with DNA amplification technology. Looking at the Quest website, this could range from a particular type of influenza swap to genital herpes to human papilloma virus.
The point about needing a graduate degree to understand this is well taken. The above labs could fairly easily be described as screening for infections of the female reproductive tract. However, asking a physician which specific procedures he or she performed that day is akin to asking a programmer which procedures he or she used that day. Either way, understanding the answer is going to require some technical knowledge.
A couple years ago i had a 'scope ACL reconstruction from a volleyball injury. The MRI showed a clean break and undamaged meniscus, and after surgery the doc said the meniscus was clean, so great..... Then the bill. Right at the top there was a $5000+ charge for a meniscectomy. When I inquired about the charge the doc said he saw a 'frayed edge" while he was in there and trimmed it off. Insurance codes make no distinction between a quick trim and a complete radical reconstruction. So, no doubt he trims every patient. So to speak.
$1300 or roughly the cost of a single injected dose of morphine from my last hospital bill.
Freedom is merely privilege extended unless enjoyed by one and all.
Mod parent up, except for the bit about "call them up."
After my (largely broke) father passed away in California I had about twelve health care providers after me (as power of attorney then as estate administrator) for about $300K of my father's medical bills. Instead, I spent about $2K (of his remaining "small estate" - look it up) on a good attorney and walked away paying NOTHING.
If you need to fight back, my advice is to never do anything over the phone, or in email. Always communicate by paper letter, certified if necessary, with signatures and official letterhead.
While HIPPA has good parts and bad parts, one of the things it is routinely used for is to provide "privacy" as an excuse for anything a healthcare organization doesn't feel like talking about, in the same way that "privileged" or "classified" is used by governments.
But this article could have done a LITTLE research. ICD codes are for diagnoses, CPT are codes for treatment. CPT is a subset of the HPCPS codes; colloquially, "CPT" is used to refer to all HPCPS codes, even if technically Level II and III HPCPS codes are not CPT codes.
So, a lab would bill for CPT codes, and a physician will record an ICD code in the patient's chart.
I don't necessarily think it's unreasonable that it's going to be hard to find plain-english explanations of the codes... there is inevitably going to be a lot of specialized jargon for such a complex field. But certainly the error rate is shameful. And all patients should receive an itemized bill, or have it easily available (like on the hospital's billing website.)
$1300 error for a $10,000 hospital bill. That is a three hour Emergency Room visit, maybe less.I know, I've had to go to the emergency room for an eye injury and the bill was close to $15,000 (Fifteen Thousand), and including waiting time to release was about 4 hours. You want to know why this shit is expensive? I saw a dozen "Non-emergency" patients in the waiting room, a number of them went in before me (my eye was gushing blood). I won't tell you why, because you'll call me a troll. My guess is my bill paid for their bills, and a few others.
Agent K: A *person* is smart. People are dumb, stupid, panicky animals, and you know it.
I'm pretty sure there are acute illnesses that don't involve gushing blood. And sometimes your only recourse is the emergency room because the doctor's office is closed, the urgent care clinics only want to treat strep throat, yeast and bladder infections and won't prescribe any pain killer stronger than baby aspirin.
The NY Times has chronicled many explanations for high bills that have nothing to do with overuse of services. Like every person with a pulse in the ER bills their services separately, even if they don't do a damn thing. I badly mangled (and ultimately need to amputate) my left ring finger and I had a $1300 bill from the ER physician whose only "service" was to ask me if I did it on purpose.
And God forbid you should need surgery and the surgeon brings in his "out of network" business partner to consult in the surgery and you get hit with an uncovered four or five figure bill from them, too. I honestly think they overcharge on purpose so that both the "negotiated balance" is nothing to sneeze at for an hour of "work" (I'd like $5k/hr, too) AND they can write off the unpaid portion of the bill as a tax loss, too, cutting their gross income.
All of this is just bullshit designed to run up fees as high as possible. Which I guess was all part of the grand game when comprehensive insurance actually was, but now that it's not it's just so crystal clear how it's nothing more than a money grab.
That's not true at all, at least in my experience living in Canada. You can go to the doctor whenever you please. There are certain procedures they aren't supposed to do because they aren't necessary.
They got rid of yearly medicals where they would run a bunch of blood tests even if you lacked symptoms or reason to be testing it. If they think there's something actually wrong with you, a blood test is no problem, and is done. But there's very little reason to send people for blood tests when from all other accounts they are perfectly healthy.
But if you actually have something wrong with you, or even a medical concern you want to ask about, you can just book and appointment, or walk-in to a local clinic or the emergency room, depending on the severity. There's also other options like a nurse hotline to answer your medical questions. Call up a 1-800 number and you get a registered nurse to talk to about your concerns. They can tell you if it's worth going to see a doctor, or if you should just take an over the counter remedy so we don't waste the doctor's time.
Also, it's worth pointing out that with a system like they have in the US, some people with lots of money have lots of choice and can see a doctor whenever they want. However, the vast majority of people are not that well off, and actually can't possibly afford the care they need. Their waiting time is forever, because they will never be able to afford the care they need. They can either choose to get care and go bankrupt in the process, or fore go care and hope it clears up on it's own.
Anthropic principle: We see the universe the way it is because if it were different we would not be here to see it.
American healthcare compares favorably with European healthcare when you take everything into account.
What aspects specifically? In the US the most common cause of bankruptcy is medical bills. That just pushes the unrecoverable costs on to other people who then have to pay even more. Insurance companies get to decide what you can be treated for, rather than doctors allocating resources by medical need. While there is some excellent care available in the US, it isn't universal so basically you either get really good but expensive care or can't afford it and get terrible care.
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SJW, n: "Someone I don't like, and by the way I'm a fuckwit" - AC
This is trivial, given that there are only a couple of federated diagnostic testing services in her area.
Looks like a bacterial infection of some kind, although they also checked for Pappilomavirus, two other STDs, and a fungal yeast infection, BVAB2, and strep.
87481 SureSwab ®, Vaginosis/Vaginitis Plus
87481 SureSwab ®, Bacterial Vaginosis/Vaginitis
87491 SureSwab ®, Vaginosis/Vaginitis Plus
87491 SureSwab ®, CT/NG, T. vaginalis
87491 Chlamydia/Neisseria gonorrhoeae, T. vaginalis, Qualitative, TMA and HSV 1/2 DNA, Real-Time PCR, Pap Vial
87491 Chlamydia/N. gonorrhoeae and T. vaginalis RNA, Qualitative, TMA, Pap Vial
87798 SureSwab ®, Trichomonas vaginalis RNA, Qualitative, TMA
87798 SureSwab ®, Vaginosis/Vaginitis Plus
87798 SureSwab ®, CT/NG, T. vaginalis
87798 Trichomonas vaginalis RNA, Qualitative, TMA, PAP Vial
87798 Chlamydia/N. gonorrhoeae and T. vaginalis RNA, Qualitative, TMA, Pap Vial
87798 Chlamydia/Neisseria gonorrhoeae, T. vaginalis, Qualitative, TMA and HSV 1/2 DNA, Real-Time PCR, Pap Vial
MEDICAL DIAGNOSTIC LABORATORIES, L.L.C.
105 Chlamydia trachomatis
127 Group B Streptococcus (GBS)
164 Bacterial Vaginosis Associated Bacteria 2 (BVAB2)
These are probably not test codes that she should have published, given their sensitive nature.
I do agree with her assertion that medical billing is kind of terrible.
On the other hand, they intentionally make billing and coding as difficult as possible so that the doctors office has to correctly code it to the insurance companies liking before they are obligated to pay. Usually a medical office will try a couple of times, and then give up if they don't hit pay dirt, and just send the bill to the patient, and let them argue with the insurance company long enough to damage their credit for non-payment, or pay it out of pocket to save their credit.
HMOs are absolutely the worst for this, followed by PPOs.
I would have much preferred a single payer system, like Richard Nixon wanted (he was the first president to propose a national health care system), rather than the TARP III bailout for the insurance companies which we ended up getting with the ACA.
Not only do we have medical bills (or EOBs) that are completely incomprehensible, we also have a price structure that's treated like a trade secret while also being a work of fiction. My medical expenses for the last year were billed at 4x the amount that was actually paid by my insurance company.
A Pirate and a Puritan look the same on a balance sheet.
Back in the 90's I did some IT consulting work for a lady that had a consulting practice that their whole gig was they went into doctors offices and showed them how they could use different CPT codes for for various procedures and make more money from it. So instead of using a code for say "blood sugar blood test" then would show them to use the code for a generic procedure that had a higher cost. They would do a "free" analysis of the doctors current billing's then show where they could make the doctor more money by going bill by bill to show them where they could make more money by using different CPT codes. When the doctor would hire her company (pay them $$$) they would then show which specific CPT codes to change on each bill. She still has this business and is making good money as well she is also now a lobbyist for the medical industry....
The Truth is a Virus!!!
Your French cousins must be idiots. According to the World Health Organization, France has one of the best healthcare systems in the world. On top of that, your cousins already have access to American Health Care. All they have to do is come over here and bring a ton of cash. Unless they're independently wealthy, France and never speak ill of their healthcare system again after they saw the bill from an American hospital.
You should update what you hear. Canada's health care system is ranked 7 spots higher than that of the United States, even before the ACA was implemented.
Even Forbes magazine, no socialist propaganda sheet, ranks Canada's health care system higher. And Bloomberg ranks it twenty-three spots higher in terms of efficiency.
http://thepatientfactor.com/ca...
http://www.forbes.com/sites/da...
http://www.bloomberg.com/visua...
You are welcome on my lawn.
There actually is a one-year cutoff. Call your insurance company and verify. Insurance companies require claims to be made within a year of the date of service. Some are willing to make exceptions on a case-by-case basis if you specifically call them and ask. Usually, when a medical biller makes a mistake, they just send the full incorrect balance to the patient. I know this because I used to write medical billing software at a small company and provided tier-2 support to the billers.
If you can confirm with your insurance company that these folks made a claim too late and that it was denied for being late, then you have grounds to complain to your state Attorney General and/or Department of Insurance. If you haven't paid that bill yet, don't. Call that billing office and complain. Ask your insurance company to do the same (they usually will.) Ask for a copy of the denied claim with the little codes on it. It will say that the claim was denied because it was late.
If you have paid that bill, then you might want to consider a lawyer because that doctor isn't going to send you a refund without a fight.
Unexplained amnesia; unexplained edema; loss of eyesight or hearing; urinating blood; post transplant fever; chest pain; ischemic attack; blackening or other discoloration of body part; loss of sensation... all trump simple bleeding