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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."
Welcome to the Panopticon. Used to be a prison, now it's your home.
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.
Since you can't legally share a lot of patient information with "unknown third parties", a consequence is that bills are going to be decidedly lacking in specific information. Even if you want to ascribe that to malice, it isn't necessarily the hospital that you should point the finger at first.
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.
The plot line of Better Call Saul is that Jimmy found out a nursing home was overcharging senior citizens and he built a fraud case. They planned a 20 million dollar lawsuit because of fraud.
Funny in medicine, it's standard operating procedure.
I want my doctors well compensated, and I don't even mind seeing dozens of new hospitals being erected throughout California with the latest in technology. But the graft needs to stop.
"Who are you?" "No one of consequence." "I must know." "Get used to disappointment."
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.
That is all.
Indeed
Sod Single Payer, if they have to pay fraudulent bills like this.
The cost (and confusion) of all this admin is one of the reasons the USA has the most expensive healthcare on earth.
Code sets like the International Classification of Diseases have been *enormously* bloated over the years. You might think this has less to do with collating accurate statistics, and more to do with providing a means for insurance providers to claim that the "wrong code was used" and deny claims. I couldn't possibly comment.
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.
as a senior administrative manager for a large health insurance company I see no reason why customers are boggled over these codes. Any schoolboy (provided your school wasn't free) could decypher this kind of billing. Anyhow, to clarify:
Code 105: we've run out of those little salmon things on the yacht in the hamptons. naturally we would call upon customers for this expense.
Code 127: truffle spread in the lounging room of the manor has expired. normally we do not assess this fee, however since we've gone to the trouble to obviously dispatch a manservant for fresh baguettes, this must be accounted for.
Code 164: The good luck brandy in the maybach has been found to clash with the petit fours and as such we will need to purchase a reisling instead. Part of this fee goes to jet fuel for the arduous trip to germany.
CPT codes: 87481, 87491, 87798: These are the inventory numbers for the delightful new mercedes we intend to purchase after returning from germany. The autobahn really is delightful you know.
Good people go to bed earlier.
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.
Why? Because if you have tax free medical savings accounts, couple things would happen. As with the so called social security trust fund, congress would raid it, and would have NO money in it. Giving POWER to the citizens, goes totally against congress, the senate & the white house. We can't have the people having any power...it would make the government not needed, and would take away OUR power. Sad, but true.
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..)
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.
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.
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
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.
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.)
These hidden costs that cannot be challenged is the end result of a "free market" system. Sooner or later, when it's dog eat dog, you get a very big, very mean dog who just gives no fucks.
You are welcome on my lawn.
"We've not seen a lot of pressure to standardize medical billing, but there's certainly a need."
HIPPAA, the entire move from NSF billing format, ansi 837pro, switch from ICD9 codes to the completely batshit insane ICD10 coding which just invites fraud by overspecification. Really it takes a truly great news outlet to discard the past 20 years in the field.
Every CPT code is specific you can google what any of them mean, example from the article
https://www.google.com/search?...
The rub is not only was the system easier for doctors offices before the changes, the standards had gone through many years of refinement through use. The effect of the move to the current standards was to force many small to medium medical software firms out of the business. Huzzah.
A process started during the Clinton administration, followed through the Bush administration, and still going on during the Obama administration. If you think government is going to help you, solve your problems, and make life more fair, there's some mighty good evidence that the exact opposite is what happens.
Because your person from the bank says "Sorry you'll have to come into a branch with ID, I can't provide that information over the phone" or "Sure, I'll just need to know your social security number and the pass code on your account" rather than "no we can't tell you because privacy".
A simple "We can mail that information to the address recorded on the account" would do. You know, tell the person how to request the information instead of just saying "no you can't have it".
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.
Hell of it was I'd just switched jobs and didn't have a new insurance card yet, but was actually insured. Over the course of my career, I've probably paid $20,000 or so worth of medical insurance and I've had the insurance companies weasel out of paying anything every single time I've had to have a medical procedure. And the total cost of those procedures so far has been significantly less than $20,000. I've had three trips to the ER or urgent care over 25 years, totaling about $3000 worth of care. $1000 of which was for a moth raping my ear.
So fuck the medical system and fuck the insurance providers. Over the past three decades, I'd have been better of with a jar of leeches. At least those are honest about sucking your blood.
I'm trying to teach myself to set people on fire with my mind... Is it hot in here?
As a former employee of a large insurance carrier in the US, I can tell you that the insurance carriers would love it to be simpler as well. My daily job was to sort out insurance claims and billing issues for customers, contacting Dr offices and hospitals. Some were great to deal with, and happily corrected the occasional error. Some were a constant may-as-well-put-you-on-speed dial and they were never wrong, just ask them. So many hands in the mix, so many variations on training, and so often, easily corrected errors that should never have happened in the first place. And from the carrier side, you can't tell an office, "you billed this with the wrong code" - legally hands are tied. Have to guide them and hope the light goes on.
And they'd never tell the patient that if you go in for a procedure, you'll be billed by the facility, the doctor, the anesthesiologist, the labs, and maybe assistant surgeon all separately.
I left to get back into my original IT career, but I can tell you the people, at least where I worked, really did care about the customers/patients and were just as frustrated with the system. The executives constantly were both asking for and implementing ideas from the rank and file, and were very open to any suggestions. They all wanted a simpler system, and were doing what they could do to make it like that, while still following the plethora of laws that need to be followed.
{} ------ When I think of a good sig, I'll put it here
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.
A young doctor and an old doctor chat over the water cooler.
Asks the old doctor: "So, what did you treat mrs. Smith for?"
Young doctor: "$17 000."
ODr: "No.... I mean: what did she have?"
YDr: "$17 000!"
Free, as in your money being freed from the confines of your account.
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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.
Not sure what you're smoking. Canada has quite a healthy private health care industry:
http://www.cbc.ca/news2/backgr...
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!!!
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