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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."
Part of the problem is caused by the disconnect that is a result of how Insurance companies are selected by individuals. I don't have a very free opportunity to choose who my healthcare insurer is, so it becomes a 'it doesn't matter' issue- I can't chose a more frugual insurer with a lower rate, so since I can't choose one that will bird-dog the itemized charges by a hospital., may as well just go along with it.
Our Health Insurance should not be selected for us by the Human Resources department where we work. The way to do away with this 'interesting' phenomena is to eliminate any tax benefits for a company providing healthcare for their employees. Take away that 'perk' to the companies and more companies would choose to either offer a direct payment 'perk' to employees to choose their own health insurace, or raise pay overall because they would no longer be dumping money into a 'health plan.' Just get rid of the tax incentive that pressures companies into 'offering health benefits' and allow people to spend their health care dollars the way they choose.
Not collections.
Challenge it. I MAKE THEM explain every line item, especially if I think it's bullshit.
I've made them write off bills because they refused to explain charges.
I blew out the tendons in both of my legs in July 2013 in a weird trip/fall, and went to the hospital for surgery to repair the tendons. I recieved a bill in February 2015 from the anesthesioligist for $1400, which is like 22 months AFTER the fact.. The billing was from one of those third-party physician billing companies, and their excuse for WHY it took close to 2 FUCKING years to bill me for that service??? I quote "The doctor only sent us the info in January 2015"... There should be some kind of statute of limitations on this shit, but I'm not holding my breath...
THANK YOU, Edward Snowden!! Americans owe you a debt of gratitude (whether they know it or not..)
The complexity of medical bills is only part of the story. Hospitals and surgical centers pretty much have to do this based upon the way insurance companies and Medicare allow or disallow coverage in a very granular manner. Just as big of a problem, at least from my experience over the last few months of having to get my wife through three surgeries, is that what you see on your initial bill you get can be very different than you actually owe, especially from surgery centers. And everybody bills separately -- the facility, the doctors and anesthesiologists, radiologists, pathology labs, etc. all send separate bills at different times.
Calls about details often went to outsourced billing providers, who immediately send you an invoice so they can begin collections. Numerous times this happened before the insurance company fully reviewed and paid on the bill. And even afterward, there were a few instances where the bill I received was hundreds of dollars more than what was submitted to the insurance company. Most of these billing providers have websites that you can use to pay a bill, but they are little more than credit merchant portals, they are not a view for billing details or any submitted payment. Any communication of documents with these billing providers often times had to happen via FAX because they did not have a secure mechanism to send information back and forth. It's like being trapped in the '80's.
This could all be much simpler.
None of these changes involve socialism, single-payer, etc. However, the complexity of our billing, and the administrative costs associated with it, compared to other industrial countries, leads ammo to those that want to get rid of the kludge that is "Obamacare" (which really was "Baucascare") and just go to single-payer.
Health care is socialism, even in the USA, so pussyfooting around and pretending it's not just gets you the worst of all worlds.
It's inherently the case that medical care is socialist because in any civilised society, the idea that someone dies of a preventable illness just because they're poor is unacceptable. Wealth comes and goes, illness is random. Even rich people would not accept stepping over bodies of people who just dropped dead in the street because they couldn't get basic medical care. Even rich people would not accept their child being infected with TB because they happened to wander into a ghetto of poor people where disease was rampant, and even rich people do not accept the idea that if in a couple of decades when their awesome corporation has been outcompeted in the market, bought by a competitor and they were then fired, that they might be left to rot at home, being eaten by a treatable cancer.
The moment a society accepts that someone who turns up at ER with an injury gets treated even if they can't afford it, that country has accepted a socialist idea. America has accepted that idea, which is why hospitals have to provide emergency care to even uninsured people and they pay for it by effectively taxing people who need other kinds of work. At that point you don't have a free market any more - free markets are not defined by customers who cannot negotiate and governments that step in to pay whatever price is demanded at the last second. So you might as well go all-in and just get it over with.
People often argue that this would result in no accountability and the like, but the example of the UK seems to show otherwise. The NHS (national health service) is always a huge factor in elections. Politicians fight over who is best for the NHS constantly. In America politicians try and motivate voters by painting their opposition as weak on the war on terror. In the UK they motivate voters by claiming the opposition is engaged in a war on the NHS. Yes, the accountability is very top down and hardly local - it's a flawed system in many ways. But at least the UK calls a spade a spade.
The usual arguments as to why
Single payer is bad. Do you want to know why? No competition. Imagine our politicians and doctors running our medical profession the same way our politicians and educational establishment worked together to destroy education in this country?
Do you want to know what will work at much lower cost than what we have? Turn the hospitals into co-ops. Instead of paying an insurance company, you pay a hospital for a monthly membership. If you have to go in, everything is already paid for. But, if you live in an area with a large enough population, you'll actually have choices, which will force the co-op to compete on price, efficiency and results with other co-ops. Perhaps the various doctors and other medical professionals in the area then come to an agreement with the various hospitals that they will treat your hospital membership like insurance, and the hospital could pay out for your preventative care like your insurance company. Or perhaps the co-op will hire the necessary personnel to provide all care except for extraordinary things (Exceptional care only provided by research institutions, etc, which they could contribute a certain amount to whether used or not, or pay as you go like insurance.)
With this model, you'll get the benefits of single payer with the added benefit of having choices, so you don't get stuck in a situation where there are 3 month waiting lists, but you can't do anything about it because you have no choice.
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.
We had something similar happen. The lead surgeon for a scheduled surgery never told us that he would need to bring in a second doctor, and of course his partner wasn't on our network. With no negotiated discount on service rates, his partner was paid more by insurance company (at 70% "out of network" payment on the full charge) than he was (at my 90% in network rate, after the massive "negotiated" discount). This was for a multi-hour invasive procedure where the book rates for the primary and secondary doctors were in the $40-50k range each.
Supposedly we owed the 30% coinsurance for the partner ... but it's been five years now and he never sent a bill. I only know about this at all because of the insurance statements. I think they aren't going after us as I have a better fraud claim against them. (We confirmed in writing that the primary doctor was on our insurance prior to the surgery. I could argue that he should have mentioned that his partner wasn't. We never once met or even saw the partner though maybe he did show up during the surgery itself when no one was awake to notice.)
It doesn't hurt to be nice.
This is one of the biggest bullshit issues with the system. Why is a simple prescription $550 "retail" but the negotiated insurance rate is 1/5 of that? It's like they are trying to screw over people who have to pay out of pocket.
Real-world example: When my wife, Sue, was diagnosed with a Glioblastoma multiforme (brain tumor) in Nov 2005 (she died 7 weeks later) the list price of a 1-month supply of her chemotherapy medication Temodar was $11,000. The co-pay on my BC/BS plan would have been $1,100 (10%). The co-pay on her Optima plan was $40.
Pro-tip: It's never a good thing when the pharmacist says, "I hope you have insurance."
Remember Sue...
It must have been something you assimilated. . . .
On an extremely minor scale, I was at a fast food restaurant the other day, and when I asked for a 30oz cup, the guy at the register rung up the 44oz. So I grabbed a 44oz, and he gave me the stink-eye. I wonder how many people he overcharges every day.
Thankfully there is no "miscellaneous" charge at fast food places, unless you count chicken nuggets.
>> "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.
Actually I used to write about medical software for the medical magazines, when they were first installing it. It was indeed pretty haphazard. They started out as billing systems, for which it worked pretty well, and tacked on other modules, like prescription drug ordering, for which it was not all that successful.
One of the major medical office systems was written by a chiropractor, who designed it after a general accounting program that was used for hardware stores or restaurants and modified for each customer. It worked great for everything that a medical office had in common with hardware stores, but not for the unique stuff that doctors had to do, like saving medical records and reminding patients to come in for followups.
The main thing that medical software did well was meet the billing needs of the insurance companies. They didn't meet the needs of doctors too well. If the doctor didn't repeat every fucking thing he did into a record field, the insurance company wouldn't pay for it. They wound up with enormous billing records, with field after field of data that the insurance companies decided it would be "nice to have," but were useless for doctors (is this prescription a pill or a capsule?). Even today, doctors complain that they have to spend an additional hour a day filling in EMR forms.
What they don't have, and still don't have, is a short narrative that would take 4 handwritten lines in an old medical record, explaining concisely what the fucking problem is with this patient and what the doctor thinks is the best way to manage it. Instead they wind up with a 100-page record that literally no one ever reads, most of which is for the irrational requirements of the insurance company, most of which is transmitted unread to the insurance company's computer.
So the insurance companies are basically spamming the doctor's medical records with billing trivia.
I saw a good book on this recently called the Digital Doctor by Robert Wachter http://www.amazon.com/The-Digi... although if you don't want to buy it you can just read his New York Times op-ed http://www.nytimes.com/2015/03...
The great thing Wachter did was go to Boeing and talk to the engineers who designed jet cockpits about human factors design. The EMRs, which peoples' lives depend on, were designed and pushed on doctors without the basic usability testing that an auto company would use for a cup holder.