The Medical Bill Mystery 532
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."
FTYF, Submitter (Score:5, Funny)
Re:FTYF, Submitter (Score:5, Informative)
$1300 or roughly the cost of a single injected dose of morphine from my last hospital bill.
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Or 13 patient gowns, at a cost of $100 each, from my last bill
Re:FTYF, Submitter (Score:5, Insightful)
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."
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How often do you hear of (or more likely, have experienced) a billing error that benefits the customer? Not very damned often. Granted, if/when it does happen, it's likely the benefactor keeps his mouth shut so you don't hear of it happening as much, but then again, OTOH when they get "caught" (you know the accountants will track those errors down eventually), that nullifies it anyway. Yet I bet nearly every one of us has dealt with at least on
Re:FTYF, Submitter (Score:4, Interesting)
Thankfully there is no "miscellaneous" charge at fast food places, unless you count chicken nuggets.
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Re: FTYF, Submitter (Score:3, Insightful)
You can guess all you want, you don't know them or their medical needs.
Re: FTYF, Submitter (Score:5, Informative)
Re:FTYF, Submitter (Score:5, Informative)
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.
Re:FTYF, Submitter (Score:5, Interesting)
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.)
Re:FTYF, Submitter (Score:5, Insightful)
The NY Times had a whole article on this phenomenon:
http://www.nytimes.com/2014/09... [nytimes.com]
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.
Re:FTYF, Submitter (Score:5, Informative)
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.
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In other words, you have to go to a lot of bother that really shouldn't occur to begin with. ALL billing artifacts should make sense BY DEFAULT. It should not require extra special diligence on the part of a patient (or any other sort of customer) to get a real bill or see what the real costs are.
The fact that this is not the norm is directly attributable to the "someone else will pay for it" mentality.
nonsense (Score:5, Insightful)
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.
Single Payer (Score:3)
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
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Yes, there are too many market forces keeping the prices down. It's a race to the bottom. People, stop all this miserly shopping for the cheapest medical care! Sure, your tiny Wal-Care bills look attractive but have you considered that if you keep doing this, you're going to cut more mom'n'pop providers out unless they are also able to viciously cut costs?
We need to put Wal-Care (and other super-slim-margin health care providers) out of business, in order to protect the health care profession!
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Single Payer doesn't solve the problem.
You want to fix the problem, make it "single price", where insurance pays what cash pays. Right now, "negotiated pricing" is fraudulent pricing.
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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.
When you go to the urgent care they ask questions that shouldn't be relevant like "how close are you to your deductible?" That just tells them how much shit to tack on the bill to try to get away with before insurance decides they are only paying 40% of the bill anyway. Somewhere i
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This used to *really* piss me off when I had a pre-Obamacare individual policy (because I was a contractor) that excluded coverage for anything that I'd ever received treatment for in the past. Specifically, the fact that if they DID exclude something from coverage, they didn't even have the decency to at least soften the blow by letting you pay the steeply-discounted rate THEY would have paid the doctor if it were a covered procedure. It felt like getting doubly-screwed... not only did they refuse to pay,
Re:nonsense (Score:4, Interesting)
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 [wikipedia.org] (brain tumor) in Nov 2005 (she died 7 weeks later) the list price of a 1-month supply of her chemotherapy medication Temodar [wikipedia.org] 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... [tumblr.com]
Re:nonsense (Score:5, Interesting)
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.
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I think they meant that there's no longer an option to think that society is just them and their immediate family & friends, that they could no longer ignore the plight of other people who are so much more than what you see on the surface, and all that mucking about with taxation, a subject much like society itself, is a complex thing that is full of nuances and consists of more that what you had for breakfast yesterday.
But that's just what I think about people who choose to jump right away on the if th
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No, they're simply not linked. That other people need stuff is a fact. I'm not averse at all to society helping out people with genuine need. My personal viewpoint is that my place in the world is just a moment in time. I as well as my family and friends could be in very different circumstances in the future. For that matter, some of my family are really not well off anyway. I just disagree with the notion that because a subset of people can't provide something for themselves, we should have the gov
Re:nonsense (Score:5, Informative)
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.
Re:nonsense (Score:5, Insightful)
More like by having a large land mass and being mostly spared from WW1 and WW2.
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Re:No single payer (Score:5, Insightful)
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.
Re:No single payer (Score:5, Funny)
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.
Re:Never happen (Score:4, Insightful)
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.
Re:Never happen (Score:5, Insightful)
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.
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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.
Where I don't disagree in principle, I think that any such law should allow for discounts for pay upon receipt of service. If you pay the provider at the time the service is provided and don't force them to file your insurance, wait for the payment and incur all the costs for staff, billing, postage (etc) and they want to offer you a discount, they should be allowed to do that. However, outside of that, everybody pays the same price for the specified service and these prices MUST be disclosed IN ADVANCE o
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Free Market is realistic pricing. Single Payer has no such function. The assumption is that single payer is better that free market, isn't supported by anything. You take the US investment into health care, which the rest of the world enjoys, and you have crappy healthcare for everyone (like in France).
Re:nonsense (Score:5, Insightful)
"holding private companies accountable is the solution"
So government regulation is the answer then?
Re:nonsense (Score:5, Informative)
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.
Re:nonsense (Score:5, Interesting)
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
Different Issue (Score:4, Insightful)
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.
Re:nonsense (Score:5, Insightful)
Boy, having socialized health care has really taught Israel, Canada, Australia, New Zealand, Singapore, Japan, Denmark, etc etc etc a lesson. That's why they're all full of "Bolsheviks" now. Hell, you go to Singapore, and it's nothing but Bolsheviks all the way down.
You stupid SOB.
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Japan and Germany are specially well suited to welfare programs in general because of their culture. They're not going to abuse it or run amok like Italy or Greece. You can't just rip a social system out of it's cultural context and expect it to just magically work.
What I hear from Canadian patients inspires no envy what so ever.
Re:nonsense (Score:5, Informative)
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... [thepatientfactor.com]
http://www.forbes.com/sites/da... [forbes.com]
http://www.bloomberg.com/visua... [bloomberg.com]
Re:nonsense (Score:4, Insightful)
That's why I specifically picked media outlets from the "free market" Right. So how about the Wold Health Organization?
How about the Kaiser Foundation? They know a little about health care.
Have you ever wondered why you don't see people from Denmark or Germany or Sweden or Singapore flying over to the US for the superior health care? In fact, you know those stories about all the tens of thousands of Canadians running to the US for health care? It turned out to not be true.
For that matter, have you ever wondered why you don't see those populations fighting to flee their Socialist hellholes and coming to the US as political refugees?
Re:nonsense (Score:5, Insightful)
And most British people look on the American healthcare system as a stark warning about what happens without an NHS.
Re:nonsense (Score:5, Informative)
Re:nonsense (Score:4, Funny)
A dose of socialism is just the bitter pill that might finally convince .....
Bitter pill ,,, that will by $275 please
Re:nonsense (Score:4, Insightful)
For some reason, pretending that a single poorly implemented health care system is representative of all single-payer systems has become an American past time.
There is private health care in Canada too (Score:3)
Not sure what you're smoking. Canada has quite a healthy private health care industry:
http://www.cbc.ca/news2/backgr... [www.cbc.ca]
Re: nonsense (Score:5, Insightful)
Really? We in countries with single payer are clamouring for a system more like America's? That's fresh. America's healthcare system is a boogieman concept here, the sort of thing that one scares voters with - "my opponent's policies will make out healthcare system end up like America's!" Even conservative Americaphiles are usually scared of it.
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People that are genuinely poor have a public option to fall back on.
People that are not genuinely poor are merely confronted with services that are as expensive as the consumer products they willingly indulge in without ever considering the implications.
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"taxpayer control"?
You don't live here, do you?
Re: nonsense (Score:5, Insightful)
Single payer would bring this under taxpayer control.
The hell it would. Single payer would put it under the control of a HUGE bureaucracy. Bureaucracies, as they get bigger, NEVER lead to more transparency or control by taxpayers. In fact, they lead to exactly the opposite, less visibility into what's actually going on, less control because they are hard to change.
What brings this under control is putting the customer who received the medical services in charge of paying the bills. If the customer doesn't have skin in the game, they won't care and if somebody else is paying the bills, I'm unlikely to care, Single payer only puts some low level government worker in charge of this, and they REALLY don't care. It's not their money, it's not their medical bill they won't care a bit.
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Dude, we are the only first-world country with a third world healthcare system. Wake up
Anybody who thinks that our healthcare system is third world has obviously never been to the third world. I have been to several third world countries and I can tell you that our system is hundreds of times more functional then theirs.
The biggest problem with our system is that the costs are spiraling out of control. This is due mainly to the spiraling malpractice insurance due to the litigious nature of Americans, and due to Obama's handing tens of billions of dollars of our money to the insurance compa
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Um, that's not even accurate. Our medical care is second to none in quality and capability.
You're complaining about the payment process. It's useful to go back and remember exactly what the problem is we are trying to solve, or we get solutions that don't fix anything.
I don't know where you got that from. There was an article in The Lancet comparing cancer outcomes in 4 English-speaking countries -- US, UK, Canada and Australia.
They said that the first thing to do in comparing international cancer statistics is to separate the black and white population in the US. The white US population has outcomes comparable to the rest of the world. The black population has outcomes that are much worse.
"the software industry" lol wut (Score:5, Insightful)
>> "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.
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Re:"the software industry" lol wut (Score:4, Interesting)
>> "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... [amazon.com] 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... [nytimes.com]
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.
Money quote (Score:2)
"The software industry has pretty much decided what information patients should receive, and to my knowledge, they have not had any stakeholder input."
Maybe fix this part first.
Available information limmited by law (Score:3)
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.
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By placing details information on a bill you are not sharing it with unknown third parties, atleast not any that are law abiding, and you cannot prevent all lawbreakers from getting that information.
Vaginosis/Vaginitis Plus (Score:5, Insightful)
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.
Re: (Score:2)
what are Test codes: 105, 127, 164
Re:Vaginosis/Vaginitis Plus (Score:5, Funny)
127: Does the patient have insurance?
164: Do we accept their insurance?
Re:Vaginosis/Vaginitis Plus (Score:5, Funny)
105: Destination charge
127: Additional dealer mark up
164: Dealer regional promotional advertisement fee
Re:Vaginosis/Vaginitis Plus (Score:5, Informative)
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.
Re: (Score:3)
Nearly all labs have an online LTD (Laboratory Test Directory), so it should be trivial to look it up, however without knowing which facility the testing was done at (often not the same as the facility where the samples were taken) it's impossible to say exactly what those test codes are.
The CPT codes are much more revealing, but it should be noted that many different tests could fall under the same CPT billing code, and it is also possible to bill multiple CPTs for a single test (depending on the utility o
Re: (Score:3)
The first code listed is for a SureSwab Vaginosis/Vaginitis Plus test (87481).
More generically, 87484 is a DNA/RNA amplification test for candida, 87491 is a DNA/RNA amplification test for chlamydia, and 87798 is a procedural indicator for doing a DNA/RNA amplification test where they are testing for more than one organism. That SureSwab test may be billed as CPT 87481, but it's not the only test that can be billed under that code.
Test codes are likely to be specific to the company operating the lab, so unless the lab publishes what their test codes map to, that's going to stay opaqu
Re: (Score:3, Insightful)
IAAP (I am a physician, and a pathologist at that!). In TFA, she notes that the pathology was only marginally more informative by including electron microscopy and immunofluorescent study. I'm not sure what more she's expecting. There's a reason why medical school is 4 years, residency is 3-4 years, and fellowship is another 1-2 years (after 4 years of college for most US citizens). This stuff IS hard, and yes it actually does require a graduate degree. In this specific instance, should the bill explain tha
Re: (Score:3)
IAAP (I am a physician, and a pathologist at that!). In TFA, she notes that the pathology was only marginally more informative by including electron microscopy and immunofluorescent study. I'm not sure what more she's expecting. There's a reason why medical school is 4 years, residency is 3-4 years, and fellowship is another 1-2 years (after 4 years of college for most US citizens). This stuff IS hard, and yes it actually does require a graduate degree. In this specific instance, should the bill explain that it's the standard of care to get EM and IF tests on medical kidney biopsies? Should the bill explain what those tests are? Maybe, but I've never seen a mechanic's bill that explained why part A was used and what that part is normally used for, or how often it's used/replaced. I've never seen any bill that really explained what stuff was for. It's going to be hard for most people to fully understand a medical bill, no matter how clear and un-obfuscated it is.
For medical billing, people are obviously more interested and vested in what's happening, but a lot of the times, the situation is going to be complicated. I don't know what the solution to that is, other than paying physicians for their time (instead of unnecessary procedures and tests) to explain things more clearly.
That's nice and all, but what does that have to do with anything any poster has complained about in this forum. There's a difference between not giving the care correctly and giving the care correctly and then over charging by 5-10x.
BTW, you do realize that when you put one of your medical bills (assuming it has confusing codes and huge amounts of over-billing) in the mail, and that letter goes across state lines, under some interpretations of the law (decided case law, not someone's idea of what a stat
Better Call Saul! (Score:3)
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.
Take 'Human Resources' out of the loop. (Score:3, Interesting)
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.
Welcome to Private US Healthcare (Score:5, Insightful)
standardisation? (Score:2)
Take the responsibility onto yourself (Score:5, Informative)
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.
Re: (Score:3)
And if he was to prescribe a standard antibiotic, you can buy them yourself at a pet supply.
The same antibiotics used for fish are the same that you are given. Exactly the same, just different labels and no prescription required.
Comment removed (Score:5, Funny)
On a similiar note... (Score:5, Interesting)
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...
Re: (Score:3, Interesting)
Eventually, the doctor will give up and bill the patient....
At which point, you challenge the bill, ask both doctor and insurance company to prove that the bill isn't covered by insurance, and argue about it for a couple more years....
I guess being a type A I see this differently (Score:5, Insightful)
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.
Re:I guess being a type A I see this differently (Score:5, Informative)
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.
Re: (Score:3)
Stuff like that will never get to court unless you're contesting something huge, like a $50000 bill. In my experience, just calling and contesting the bill is enough to get them to start significantly cutting down the balance. There's no use fighting individual patients over a couple thousand dollars when >90% of the patients (or their insurance) will pay without complaint.
Also, so much of the various provider bills are double charged and flat-out manufactured that it's simpler to just drop charges than
Too Many Insurance Companies (Score:5, Insightful)
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.
It's not that complicated (Score:4, Informative)
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.
It's called 'Upcoding' (Score:5, Informative)
All medical bills are mysterious. (Score:5, Insightful)
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.
The Business Model is a Big Problem (Score:5, Interesting)
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.
HIPPA is healthcare's "classified" (Score:3, Informative)
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.)
Re: (Score:3)
How do they know who's calling them over the phone? Anyone can say "I'm the patient, tell me".
If the caller explains there's a "Test code 105" on the bill, they can explain what that number means without going into patient details.
Re: (Score:3)
She called them up on the phone to ask what the codes mean.
Not telling this to someone over the phone really is a measure to take to protect privacy. How do they know who's calling them over the phone? Anyone can say "I'm the patient, tell me".
I am going to guess that you don't have much experience dealing with either hospitals or medical insurance. All sorts of things (including "mission critical" ones like prescriptions, tests and even surgery schedules) are arranged, discussed and argued about over the phone. Yes, you have to answer a set of challenge questions (i.e., social security number, policy number, etc.) to show that you are indeed the person in question, but pretty much all of the organizational business of patient care is done over t
Late stage capitalism (Score:3)
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.
NYT doesn't report news but does try to create (Score:3)
"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?... [google.com]
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.
Hospitals need to employ people (Score:4, Insightful)
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.
They just make it up (sometimes) (Score:5, Insightful)
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.
Old oblig joke (Score:5, Funny)
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!"
Comment removed (Score:3)
Mis-coding being perpitrated by doctors! (Score:5, Informative)
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....
Re: Doesn't seem lawful (Score:5, Interesting)
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.
Re: (Score:3)
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".
Re: (Score:3)
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