Medical Debt Saga Part II : Anyone know anything about OR billing?

[1monster]

Part one is here: http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=389&topic_id=1689369&mesg_id=1689369

I need to know if anyone knows what these are and if it is appropriate to bill them seperately or if the norm is to include these with the OR charge. Also, I need to know if the cost is out of line with the norm. (The medical verification person believes that it is tantamont to double billing. The hospital has not complied with my request to provide documentation for these two charges.

This was for a triple bypass:

Cell Saver: $1,221.70
Open Heart Perfusion: $5,200.00

I got a very frosty reception from the hospital billing clerk when I called. I asked her if I could speak to her boss, but she said the boss was busy.

I asked when I could see her at the hospital. She anwered that if I came in within the half hour, I could see the supervisor.

Twenty minutes later I was there. Talked to the same woman who had been very unfriendly over the phone.

She told me that the reason the medical verification rep said that there was a problem with the bill was that he and the insurance company made money that way...

She was extremely uncooperative acting as though I was in the wrong for asking for docuemntation via a letter instead of talking to them in person. She stated that I was in the wrong for talking to the insurance company and the medical review rep rather than them. And that I had done nothing to take care of the problem.

When I pointed out that I had sent them a letter requesting documentation, they did not answer me, and again when I replied to the collections law firm stating that the account was in dispute because the hospital did not supply the requested documentation, she stated that they did get in touch with us by sending a statement. She said they left a message on my home phone (I didn't have an answering machine until last week and I haven't hooked it up yet) and my husband's cell phone BEFORE I sent them the letter.

I asked to see her supervisor, the one she told me would see me if I came in within the half hour.

"She's not here. She has left for the afternoon," said the woman.

:grr:

The gave me a print out of all the charges both paid and unpaid. I asked for a separate print out of the charges that were not paid, but she said that was impossible. (Four years ago, it was not impossible...but maybe they got new software.)

I came home and got a call from the medical bill verification company. A new rep was handling this case.

He told me that he had spoken to the same woman I saw at the hospital an hour before I got there explaining that he was the new rep for this case. He said she was polite, but not cordial. (Please note that she did not tell me that the rep had been in touch.)

:grr: :grr:

The hospital billing clerk told me that insurance companies "never pay 100% of the hospital bills" and indicated that the over $7500.00 disallowed charges were due to "acceptable and customary charges" type thing.

The new medical review rep sent me via e-mail a print out of all the charges and why had not been paid and why. Of the $7500 plus outstanding balance, that charge was $21.20...

I'll be happy to write a check for that immediately.

In the meantime, the medical review rep is talking to the insurance company and said it is possible that if the hospital provide documentaion and a reasonable explanation for the above items being billed separately, the insurance company might pay up.

But the hospital is saying "PAY UP NOW OR WE WILL START COURT PROCEDINGS"

(My offer of $1,000 was turned down flat. She said nothing less than $5000 which is almost as bad as $7500... sigh.

[pinto]

1. re: cell saver and open heart perfusion

cell saver - refers to an "auto transfusion" during surgery. i.e. your own blood is returned to you during the procedure. A cell saver keeps your blood components viable for re-transfusion.

open heart perfusion - refers to the heart/lung life support system used during an open heart procedure.

Good luck with the billing negotiation(s), I know it can be a morass and takes some tenacity to resolve.

(My guess is that the two billings are from the teams that performed those functions while the surgical team performed the by-pass. But it would be *best* to query your lead physician on what's what. They ought to be able to give you professional description of both.)

Hope your surgery went well.

[1monster]

14. Thank you. I now understand why the insurance company is thinking that

the two charges should have been included with the OR charges.

The doctors all billed separately from the hospital. I've had bills from people we've never heard of...

[knitter4democracy]

16. Excuse me?

Which doctors? If no one remembers seeing them or hearing from them, and if your chart doesn't mention them, it's fraud, plain and simple. I know a doctor who got slammed for that (billed level four for patients he didn't see but called in order for, the *&^%&^). Big fine.

Get a copy of your chart. You need that asap. It'll help with figuring out the bill, too.

[izzie]

2. I get lost on medical bills and my daughter said to wait a while

so every thing comes in and you can lay them out and figure it out. She is a RN. I once was with my son in SF for an operation and he got PART of his bill. It was about $68,000. I almost fainted but ins. paid it all. He had had a operation that lasted about 12 hr. That was operating room and the hospitals bills were not with it. Room etc. Good luck. I can hardly figure out the eye check up and what I owe when I am done with it.

[Uben]

3. Is it a private hospital?

It's a racket, as if you haven't figured that out yet. They have to furnish you with an itemized bill if requested.

TWo years ago, I broke my left tibia. When the OR bill arrived, I was charged for an additional surgeon, whom I knew was only a physicians assistant (he was in school to be a surgeon at the time). I informed my insurance company of the error, to which they told me that was between me and the hospital. WTF? So I called the hospital and asked why they charged for a physician's assitant as an OR surgeon. Ruh-roh! They were caught, and they knew it! They told me not to worry about it and they would take the charge off my bill.....but they didn't. It was no hair off my ass because the insurance was paying for it anyway, but it is not right for them to make up charges. I persued it and got the charge removed. I suspect this is rather commonplace as most folks would not have the patience to stick it out and get the bogus charges removed.

Now, I really liked the PA, and the OS, but I will never go to him again because of this obvious dishonesty.

Oh, that broken leg? It wound up costing $40,000 for the arthroscopic surgery and putting two 3 inch screws in my tibia.

$10 each for a hydrocodone pill.

On top of all of that, I woke up puking every hour for twelve hours (I was on a morphine drip) It took that long for them to realize I was allergic to morphine!

(But, thank GOd for that little Korean nurse, who could barely speak English, who had to insert a catheter into my pee-pee so I could urinate! I was about to bust after 10 hours without going!)

[1monster]

7. This is a nonprofit hospital that receives some public funds and must treat

patients regardless of their ability to pay.

[knitter4democracy]

9. Now, that's interesting. You've got power, then.

Yes, indeedy! Okay, here's the deal. Call the hospital switchboard and ask for the name of the head of the billing department. Send that person a letter explaining everything that's been done to you, everything that's happened, and that you are fairly certain the hospital has been committing fraud (it sounds awfully shady to me, and I know hospitals a bit--Hubby's a doctor). CC that letter to the State AG and the state committee on hospital oversight (every state has one, I believe, and it's often part of the AG office). Make sure the CC is on her letter so that she knows you've reported it.

Not giving itemized bills, even when asked, sending it to collections and then telling you that you shouldn't deal with the collections agency, and not accepting anything less than five grand all smack of fraud to me. How much do you want to bet they accept less than five grand but the office lady pockets the difference? Humph. I've never heard of a number that high. I'd also bet the state has a legal number that they're ignoring.

If you don't hear back (and given your experience, that sounds likely), I'd go right up the chain of command. Start talking with the chief administrative people at the hospital. If that gets you nowhere, then it's time for the state to get involved. I would also put in a complaint with Medicare ( http://www.medicare.gov/FraudAbuse/HowToReport.asp )--I'm sure they don't want an audit. If they're mucking up your bill, I'm sure they're mucking up stuff with Medicare (easier to do).

[1monster]

11. The lady I talked to at the hospital billing department told me that it was

the billing department director who approved the law suit...

I still owe the surgeon and the cardiologist $1600 and $1800 respectively...

[knitter4democracy]

12. I'd contact the state at this point.

And the hospital board of directors. I'd send a letter to each one detailing what's happened and why you're upset. I'd bet that this behavior goes directly against their non-profit application and mission statement. What's the hospital's endowment size? Someone in the board's office should be able to tell you that, too. I'd put that in there.

For the doctors, they'll usually be okay if you attempt to pay at all. Contact their billing people and offer to set up a payment plan. I know Hubby's office does that. Doctors hate lawsuits, in general, and will do what they can to avoid calling a lawyer or collections agency that they have to pay for.

[1monster]

13. I don't know what their endowment is, but I know that about fifteen years ago,

they doubled the size of the hospital and paid CASH for the it. Then they decided, before the expansion was completed that they needed even more expansion and paid cash for that too.

The hospital was originally endowed in the late 19th century. They built a new hospital maybe twenty years ago moving from the original hospital.

[knitter4democracy]

15. Hmm. How many fundraisers are they doing?

If they only do one or two a year, the endowment is huge. If it's that big, they can afford to help you out, so I would make a point to mention that to the board of directors.

[MannyGoldstein]

4. Billing Is Bizarre

Basically, the hospital has agreements, written or unwritten, with insurers, so there are rules for how much to bill, and which conditions warrant which procedures. However, if the hospital is billing the patient rather than an insurer, there are no rules (to my knowledge) - they can make up any crazy thing that they want to make up.

On the other hand, what's fair is fair - you shouldn't be screwed. If the insurance company is saying that the charges that the hospital is attempting to bill to you are other than "acceptable and customary", then I would take the position that you also believe that they are not "acceptable and customary", and that the hospital is trying to rip you off.

I would suggest:

1. There is some dispute as to what's been paid, and what's (allegedly) unpaid. Somebody is making a mistake. I'd try to nail this down by getting a hospital billing person and an insurance person on the phone at the same time - many cell phones allow you to conference two people at the same time. Call one person, tell them to hold, then get the other on the line. If you continue to be the go-between for both parties, you will go nuts.

2. Do things by mail, or at least email, so you have a record of trying to resolve this. Make sure that you keep saying that you want to resolve things, but you absolutely need a complete accounting of all charges and reasons for payment or non-payment, and you absolutely need to understand the rationale for what was billed and not paid. And you need this in writing. People often become much better behaved when they have to put it in writing, and it's absolutely your right to have it in writing.

2. I'd write a letter (a letter is better than an email) that's copied to all of your elected representatives (congressperson, both of your senators, your state's attorney general, state insurance commisioner, and whoever else you see fit) expressing your utter outrage at the inability of the hospital and insurer to get this straight, and how you feel that you're being preyed upon by a hospital that is billing beyond what is "acceptable and customary", or an insurer that won't pay what is actually "acceptable and customary" - or some combination of both, and how there needs to be enforcable laws that stop this sort of predatory garbage. Make sure that you send cc: it to the hospital's president. Perhaps follow up with a phone call to your congressperson's office. In my experience, you will likely see everyone start to play nice - nobody wants to deal with the horrors that angry politicians can inflict, particularly since health care is a hot-button issue right now.

(I'm guessing that you live in a red state? I usually don't hear about these types of things in blue states.)

Good luck!

[1monster]

6. This hospital has no agreement with my insurance company. As a billing rep

once told me years ago, "We can charge anything we want. There are no laws about it."

[MannyGoldstein]

8. They Can *Try* To Charge Whatever They Want

But if you can demonstrate that it's beyond what is customary, then I expect they'll have a big problem if they take you to court and you object. Good question to ask your attorney general's office when you write - "Is it true that the hospital can charge whatever it wants, even if it's beyond what's customary, and I have to pay it?"

[knitter4democracy]

10. Not necessarily.

State laws, federal laws, and unwritten contracts with your insurance (if they bill it to your insurance at all, there's an unwritten contract) are all enforceable. They can try, but that doesn't mean they'll get it. I smell fraud.

[Bitwit1234]

5. Usually all my bills are paid by Medicare and then BC/BS with

what Medicare does not pay. Last year I had an eye examination regarding my cataract operation. I then got a bill from the Eye Clinic asking for $25.00 for a service that Medicare and BC/BS don't pay well stupidly I wrote a check. About three weeks later I got a check from BC/BS they said it was for my eye exam because the doctor was not in their system. Well that same week I got a review letter stating what Medicare and BC/BS had paid. Medicate paid 15. and change of the $25.00 the eye doctor said they wouldn't and BC/BS as their usual practice paid the rest. Well I had deposited the check and wrote one for $95.00 dollars to the eye doctor but when I got the review letter I tore it open wrote another check from which I had deducted the $25.00 dollars. I got another bill from the eye doctor requesting the $25.00 . I called told them what had happened and they said they would call the insurance company and medicare and find out what happened. Next month I got another bill for $25.00. I called and the clerk told me that BC/BS said that they had paid me the $95.00 and I owed it to them.

Where they stupid on purpose. I could not get it thru the woman's head that I was not going to pay $25.00 they had already gotten from the two insurance companies. After goodness knows how many phone calls etc I finally wrote out a check for $25.00. Then I received a call saying I had missed my usually eye appointment. I told they lady she knew what she could do with the eye appointment that they were not getting anymore money from my insurance company. I keep getting postcard reminders tho.