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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."
Screw this crap... Single payer soon, single provider eventually. Let's try to be a first-world country and not just the world's largest provider of bomb craters.
>> "The software industry has pretty much decided what information patients should receive, and to my knowledge, they have not had any stakeholder input..."
Um...yeah. I'm sure it was a bunch of developers who decided one night to pound a bunch of Mountain Dew and then set up a billing system for a bunch of multi-billion dollar hospital groups that contained hundreds of thousands of items that magically skirt around insurance limits and pre-negotiated fees, then tack on expensive and low-value items, and follow it all up by adding on mysterious charges from other providers months after the original procedures happened.
I sense this is a hoax, or at least contrived example to raise awareness. It is trivial to look up CPT codes online. The first code listed is for a SureSwab Vaginosis/Vaginitis Plus test (87481).
It isn't exactly "fun", but it is straightforward to request your actual test results from the facility, and then correlate the results to your bill. You should have results and documentation in your medical record for ancillary department services you were charged for. That is, if you want to audit everything like that to keep healthcare facilities honest. If you have insurance (either government provided, or private), then you can always have them investigate anything you see that is awry. Insurers are always more than happy to find someone to sick their attorneys on.
Better known as 318230.
That is all.
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.
1. It's trivial to look up those codes online, right? Putting "cpt code 87491" into Google shows that's a STD test.
2. I wouldn't pay it if the lab didn't explain it. Period. "She really doesn't want to pay it..." then don't. Call them up and tell them that they either explain it or you're not paying. Make them take it to court. That shit wouldn't last 5 seconds in front of a judge. Note that it wouldn't get that far - their attorney wouldn't let it.
People just need to learn how to play hardball.
Do you have ESP?
The issue is there are too many insurance companies. The core is the same, as in there's a claim and there's standardized billing codes for procedures. However, each insurance company has a different set of policies on how visits should be coded.
This has lead to health care providers hiring claims optimizers that help them code the visit to extract the most money from the insurance company. Which leads to insurance companies hiring claims optimizers to shape policy to reduce the amount they pay. Then times that by the number of insurance companies they might deal with. Add a little more complication if you're insurance is out of state and they use another companies network and policies. It's a giant clusterfuck.
This is also one of the major drivers of health care cost. There are plenty of other countries that have private health insurance. The difference is the gov't sets a common claims format and policy. They typically also set the base cost of each service (adjusted for cost of living for the area). That means the insurance companies compete on having lower administration costs and programs to make the members healthier.
The rich always have the means to seek what they think is the best when it costs more, in any category that they choose to. That's what being rich does for you.
What I want is a medical system where if I get a bill for services, I get one bill , not a bill from the hospital, a bill from the nurse practicioner, and a separate bill from the doctor that's "responsible" whom I never even saw but because the nurse practicioner asked them a question they get in on the action.
One of the real problems that the presence of medical insurance not paid for directly by the patient has created is that the patient is disconnected from the methods of payment, but not disconnected from the ultimate costs. The patient has no idea what a simple hospital visit for a minor at-night injury will cost when he's only there for a few hours, and since there is this disconnect, all of the professionals have figured out how to exploit this to bill, bill, bill!
The clinic should be the only entity to send the bill. The staff working at the clinic should be paid by the clinic. I don't care if it's a walk-in clinic for boo-boos and scrapes or if it's the Mayo Clinic handling open heart surgery, the clinic should figure out the damn bill and send one bill.
Do not look into laser with remaining eye.
Another thing is so many different people bill you and you have no idea. My wife had a surgery and we have bills rolling in for some four months after the procedure. Random doctors, labs, hospital departments, practices are billing us. For things that you don't understand at all. For things like rent for corridor space the gurney was parked on before entering the Operating room. They would glorify the corridor space as pre-op waiting area or some such jazzed up name. This on top of a per day rent for being inside the hospital.
The next step is going to be every doctor carrying an RFID detector and every patient tagged with an RFID tag. The machine will record all the patients the doctor passed by in the corridor and he/she can bill them all for looking at them.
sed -e 's/Chuck Norris/Rajnikant/g' joke > fact
Yea this.
When I read that line I said to my wife, "ERROR implies that it occasionally benefits the patient. This shit is on purpose."
An enigma, wrapped in a riddle, shrouded in bacon and cheese
MSAs (medical savings accounts) already exist, but are limited to people who choose HDHPs (high deductable health plans, with special limits) and to about $3k/yr for singles and $6k/yr for families. It's your money, going pre-tax into your savings/investment account and able to be withdrawn for medical uses tax free. It's not federal government.
What we need is a way to ensure that services are not billed to private clients (individuals) for more than large corporate clients (insurers). If I pay cash for a procedure, I shouldn't be charged 5-10X what I would be charged if I were insured.
Is it just my observation, or are there way too many stupid people in the world?
The term is "negotiated prices" by insurance, and it is nothing more than a racket. One of the fixes I propose is Single Price healthcare, where prices are the same no matter who, or how it is paid.
Agent K: A *person* is smart. People are dumb, stupid, panicky animals, and you know it.
You can guess all you want, you don't know them or their medical needs.
What bugs me about medical billing is apparently hospitals don't have any employees. Hospitals are apparently just flee-markets that provide space to hundreds of independent individuals and companies who all send separate bills for their services whenever they get around to it.
The hospital sends their own bill. Then the doctor sends a separate bill (WTF? The doctor isn't even employed by the hospital?) The EKG tech, sonogram tech, x-ray tech, all send there own bills (often months later). Anesthesiologist, separate bill.
What exactly is the hospital bill for? Apparently, the only employee the hospital has is the billing co-ordinator, who makes sure all these separate entities know who to bill.
Anyone who has had an involved relationship with the US medical care system is likely to come to the conclusion that sometimes they just make their bills up, either to increase revenue or because their record-keeping is so chaotic.
If you doubt this, consider an analogy. Suppose you took your car in for major engine repair, it was in the shop for a week, and you paid the hefty bill. Now, suppose 4 months later you got another bill from a "muffler specialist" or a "catalytic converter specialist" for $ 300, with a code saying that they worked on your car while it was in the shop, but no indication as to what they actually did (except, maybe, look at your muffler or catalytic converter). Would you consider it legit? Would you assume you are being gouged? Would you pay? (They'll take you to court if you don't.)
In my experience, the medical version of this happens every time I have a family member in a US hospital. Not occasionally, not once in a blue moon, but every time. This is one reason why you never know how much a procedure is going to cost; you don't know what bills are going to show up months later.
This issue is something not addressed by Obamacare and is actually completely different from the question of how people get insurance.
One of the fundamental flaws in the old and current system is that it is completely opaque as far as costs go. People needing non-emergency care have no way to determine which provider has the best prices and what they will be charged for. It's like buying a car..you get one price from the Salesman but when you get back into the finance office, you have all this other crap added on that you aren't sure you need or even what it is.
Until this crap is straightened out, consumers will never be able to make informed choices and the people paying the bills, insurance companies or government, will never really know what they are paying for.
Fix this and you are a long way towards a better solution for all involved.
When Fascism comes to America, it will call itself Anti-Fascism, and tell you to give up your guns.
and this is why we are fucked with antibiotic resistant bacteria strains getting stronger.
They should not be available like fucking M'nM's...
restaurants can't bill like that but the medical can?
Just think if a restaurant where the cook, busier, expeditor, waiter all sent you bills in the mail. and the menu price just cover the non labor costs and the labor costs are not listed in it.
The NY Times had a whole article on this phenomenon:
http://www.nytimes.com/2014/09...
One thing that wasn't clear is how successful doctors are in pursuing these charges if the patient actually refuses to pay (especially if in your case, as you confirmed in-network status ahead of time in writing).
I have a hard time seeing patient responsibility for this out of network gambit if they didn't approve it up front. Of course like everything else, they will line up an expensive lawyer to chase you down and make you decide whether agreeing to settle for a reduced charge of $10,000 and making it go away is a better choice than rolling the dice on a $10,000 legal defense that you could lose, upping the ante by another $10,000.
Imagine working as an IT contractor on a project and bringing in an outside consultant who then bills the company separately at 10 times the rate as the contractor. "Oh, I'm sorry but it was necessary due to project complexity." You'd get laughed at, fired and probably sued into penury if not brought up on criminal fraud charges.
Oh bullshit, bleeding trumps everything except "can't breath" , especially if it's an eye.
Apocalypse Cancelled, Sorry, No Ticket Refunds