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Medicine The Almighty Buck

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."
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The Medical Bill Mystery

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  • by idontgno ( 624372 ) on Wednesday May 06, 2015 @09:47AM (#49628807) Journal

    An audit by Equifax found that hospital bills totaling more than $10,000 contained an average undocumented "because STFU" surcharge of $1,300.

    • Re:FTYF, Submitter (Score:5, Informative)

      by SacredNaCl ( 545593 ) on Wednesday May 06, 2015 @10:16AM (#49629163) Journal

      $1300 or roughly the cost of a single injected dose of morphine from my last hospital bill.

    • Re:FTYF, Submitter (Score:5, Insightful)

      by CanHasDIY ( 1672858 ) on Wednesday May 06, 2015 @10:32AM (#49629337) Homepage Journal

      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."

      • My thoughts exactly, on just about every billing error ever.
        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
  • nonsense (Score:5, Insightful)

    by jjeffries ( 17675 ) on Wednesday May 06, 2015 @09:47AM (#49628809)

    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.

    • 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

    • 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!

    • 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.

      • 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

        • 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)

          by fahrbot-bot ( 874524 ) on Wednesday May 06, 2015 @12:24PM (#49630457)

          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)

      by Rolgar ( 556636 ) on Wednesday May 06, 2015 @11:30AM (#49629943)

      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.

  • by xxxJonBoyxxx ( 565205 ) on Wednesday May 06, 2015 @09:48AM (#49628835)

    >> "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.

    • by UdoKeir ( 239957 )
      "to my knowledge", i.e., "I'm making this up".
    • by nbauman ( 624611 ) on Wednesday May 06, 2015 @04:30PM (#49632841) Homepage Journal

      >> "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.

  • "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.

  • by WoodstockJeff ( 568111 ) on Wednesday May 06, 2015 @09:50AM (#49628845) Homepage

    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.

    • by thaylin ( 555395 )

      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.

  • by Dan East ( 318230 ) on Wednesday May 06, 2015 @09:50AM (#49628847) Homepage Journal

    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.

    • by thaylin ( 555395 )

      what are Test codes: 105, 127, 164

      • by msauve ( 701917 ) on Wednesday May 06, 2015 @10:04AM (#49629029)
        105: Is the patient alive?
        127: Does the patient have insurance?
        164: Do we accept their insurance?
      • by tlambert ( 566799 ) on Wednesday May 06, 2015 @12:27PM (#49630475)

        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.

    • 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

      • by sfcat ( 872532 )

        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

  • by Hussman32 ( 751772 ) on Wednesday May 06, 2015 @09:53AM (#49628875)

    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.

  • by Bing Tsher E ( 943915 ) on Wednesday May 06, 2015 @09:56AM (#49628923) Journal

    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.

  • by segedunum ( 883035 ) on Wednesday May 06, 2015 @09:58AM (#49628945)
    That is all.
  • No, there is no need for standardisation. There is simply a need to write clearly on the bill what it is for, or at least to be able to answer questions about it when asked.
  • by FictionPimp ( 712802 ) on Wednesday May 06, 2015 @10:01AM (#49628981) Homepage

    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.

    • by Lumpy ( 12016 )

      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.

  • by nimbius ( 983462 ) on Wednesday May 06, 2015 @10:02AM (#49628989) Homepage
    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.
  • by LVSlushdat ( 854194 ) on Wednesday May 06, 2015 @10:04AM (#49629021)

    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)

      Having gone through the same sort of thing for my cancer, the real reason it took so long is that the Doctor and Insurance Company went round and round trying to sort out who was stuck with paying for things.

      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....

  • by Trailer Trash ( 60756 ) on Wednesday May 06, 2015 @10:06AM (#49629047) Homepage

    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.

    • by xxxJonBoyxxx ( 565205 ) on Wednesday May 06, 2015 @10:18AM (#49629191)

      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.

    • by chihowa ( 366380 )

      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

  • by Kagato ( 116051 ) on Wednesday May 06, 2015 @10:07AM (#49629065)

    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.

  • by Anonymous Coward on Wednesday May 06, 2015 @10:11AM (#49629109)

    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.

  • by cahuenga ( 3493791 ) on Wednesday May 06, 2015 @10:14AM (#49629151)
    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 $5000+ charge for a meniscectomy. When I inquired about the charge the doc said he saw a 'frayed edge" while he was in there and trimmed it off. Insurance codes make no distinction between a quick trim and a complete radical reconstruction. So, no doubt he trims every patient. So to speak.
  • by 140Mandak262Jamuna ( 970587 ) on Wednesday May 06, 2015 @10:23AM (#49629251) Journal
    It is just not these indecipherable codes on the bills. I typically get explanation-of-benefits that runs like, "X-Ray radiology 800$, Paid by insurance company 100$, discount to insurance 685$, you owe them 15$". Any one without an insurance will be billed 800$. No body would pay such an insane bill. They will sell it to some debt collector at some 20 cents a dollar. The bill collector would hound the patient, add all sorts of fees and penalties and dun payments. About two thirds of the bankruptcies in USA are due to medical costs. If the lab billed honestly and charged 150$ for uninsured, 100$+15$ copay for insured, things will not spin out of control this badly.

    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.

  • by Carcass666 ( 539381 ) on Wednesday May 06, 2015 @10:28AM (#49629297)

    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.

    • For a surgery, everybody involved should bill the hospital or surgical center, and then the hospital should send me a single bill. When I get a car serviced, I don't get a bill from the car shop, the parts manufacturer and any mechanic that touched my car.
    • Any bill should not be sent to me until fully reviewed from the insurance company
    • When getting ten+ unreviewed bills for a single surgery, all of which demand payment pretty much immediately, I am not going rush to run up my credit cards. I am pretty sure hospitals do not pay their suppliers on a COD or Net 14 basis, I can't either. Give me at least thirty days to set up financing, extract retirement money, sell a kidney, whatever, to pay for $50 ibuprofen.

    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.

  • by sirwired ( 27582 ) on Wednesday May 06, 2015 @10:29AM (#49629311)

    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.)

  • by PopeRatzo ( 965947 ) on Wednesday May 06, 2015 @10:31AM (#49629331) Journal

    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.

  • by Crashmarik ( 635988 ) on Wednesday May 06, 2015 @10:34AM (#49629357)

    "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.

  • by MorePower ( 581188 ) on Wednesday May 06, 2015 @11:00AM (#49629645)
    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.
  • by mbone ( 558574 ) on Wednesday May 06, 2015 @11:04AM (#49629687)

    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.

  • by codeButcher ( 223668 ) on Wednesday May 06, 2015 @11:48AM (#49630129)

    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!"

  • by CHK6 ( 583097 ) on Wednesday May 06, 2015 @11:57AM (#49630261)
    Personal experience I find that the for-profit hospitals that I have needed services from have very clear billing. Where as the non-profit hospitals I found to be a bit murky. Now the for-profit hospital expenses were on par with the non-profit, leading me to think that maybe the insurance carrier doesn't care and prices are what they are. Or non-profit just has so much red tape they can operate as a for-profit.

    My complaint has been the cost of medicine and not the cost of care. I think the cost of care is nominal. However the cost of medicine is completely out of whack. My wife had the exact same surgery four years apart where after surgery I had to give her shots for 40 days post surgery. In both cases the exact same medicine in the exact same amount was prescribed due to a unique blood condition. The first surgery the 40 day supply cost me $150 with my insurance carrier. The second surgery with the same insurance carrier it cost me $850. I have kept the same insurance carrier and at the most coverage. My healthcare costs have more than doubled in this time. It just makes no sense to me and the poor insurance reps on the phone could not explain the reason for the insurance changes in the drug price negotiations.
  • by gabrieltss ( 64078 ) on Wednesday May 06, 2015 @01:04PM (#49630837)

    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....

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