Posted on 12/08/2019 1:48:10 PM PST by karpov
Much of what we accept as legal in medical billing would be regarded as fraud in any other sector.
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Companies are permitted by insurers to bill for “durable medical equipment,” stuff you receive for home use when you’re in the hospital or doctors’ office. That yields some familiar marked-up charges, like the sling you can buy at Walgreens for $15 but for which you or your insurer get a bill for $120 after it is given to you at urgent care. The policy has also led to widespread abuse, with patients sent home with equipment they don’t need: My mom’s apartment, for example, holds an unused wheelchair, a walker and a commode paid for by Medicare, by which I mean our tax dollars. It’s as if you were given a swag bag at a conference and then sent a bill for hundreds or thousands of dollars.
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The biggest single item on Andrej’s E.R. bill was a $7,143.99 trauma activation fee. What was that for, since every component of his care had been billed and billed handsomely?
Among the line items: $3,400 for a high-level E.R. visit. $1,030 for the trauma surgeon. Between $1,400 and $3,300 for five purported CT scans. And I say “purported” because one trip into a scanner examined the head, upper spine and maxillofacial bones, but was billed as three separate things. There was also an administration fee of more than $350 each for four injections.
Trauma activation fees have been allowed since 2002, after 9/11, when the Trauma Center Association of America, an industry group, convinced regulators that they needed to be compensated for maintaining a state of “readiness.”
Wait. Isn’t the purpose of an E.R. to be “ready”? Isn’t that why the doctors’ services and scans are billed at higher rates
(Excerpt) Read more at nytimes.com ...
Would Trump's requirement that hospital disclose their rates address this problem?
After knee surgery, I was sent TWO wheeled-walkers. (To add to the one given me at a senior center!)
Most of this kind of stuff is working the system of the insurance companies. The insurance companies like to “discount” a bill they get, only paying a small fraction. If you need to get $1000 for a procedure to be minorly profitable, and you know the insurance company is going to “discount” whatever bill you hand them by 80% then you need to find a way to hand them a bill for $5000. It’s a strange game. It’s a stupid game. But it’s how things work.
Well she is outright wrong about one thing (based on what is posted here). The hospital or physician or therapist or provider of durable medical equipment will bill the insurer showing a cost of X dollars. But depending on the negotiated contract rate you can bet that is not what will be allowed. What is allowed is usually based on what Medicare terms usually and customary charges based on that region. Insurers as a general rule accept assignment which means the service provider is paid 80% of those allowed charges and the patient is responsible for the remaining 20% of those allowed charges. Not the balance of the entire sum submitted originally.
But billing practices do mean that the real cost of services and equipment is anybody’s guess and that sure drives up costs. R
What is billed and paid also relies on how the bill is coded. “Office visit” and “Office consult” may seem to be the same service but to those paying they are not. So that is why it is very important to make sure any paperwork from the doctor’s office correctly shows the service you received.
$3,400.00 for a high level ER visit is peanuts. As is the fee she was billed for the surgeon. And yes one scan that is done of 3 areas is 3 separate items as the radiologist has to read and report each scan.
Trauma care is very expensive. I would suppose the trauma activation fee is because the hospital may need to have a number of specialist is various fields at the ready when they are notified of a patient coming in. Not only specialists but support staff as well. If there is a head injury the cost goes up. But you know the author could have looked this up.
I think that requiring them to be open and up front on pricing would go a long way to help. I had 2 procedures this year and they just will not tell you what it is going to cost. The bills just trickle in over a period of many months. I think we should have a rule requiring them to give you a few days advanced notice of out the door pricing, kind of like with real estate. Of course, there has to be an exception for emergency treatment. I am not sure how you would police that.
I am not in favor of the gummit running health care, but sometimes I feel like someone in the medical industry is doing everything they can to make that happen. If things are not broke enough to force government intervention, they they break them some more and they are going to continue that until there is no option left.
Yep, just recently I saw that the billed amount for a knee MRI was about $3200, the contracted insurance rate paid around $400.
We were billed for two lenses after a surgery for ONE eye. Somehow the billing office couldn’t understand what the problem was. One eye but two lenses???
Did have a billing clerk admit that, on a different surgery, we were getting double billed because the illegal patient ahead of us skipped the country. Never could get that fixed.
Both incidences were from Scott and White aka Baylor Scott and White. Yeah, I’m calling them out. We’ve since dumped their lousy @$$e$.
I had a successful surgery but contracted C-Dif, a highly dangerous and contagious infestion at the hospital. The medication for C-Dif was $3000.00. After Medicare, I owed the hospital $2000.00. When I told them the hospital was where I contracted the infection, they told me I owed nothing. I was out $1000.00.
Providers and Insurance companies can charge/pay/bill/discount whatever they want, in any fashion they want, by pre-approved contract agreement they want.
BUT
if you are going to charge/bill/discount/copay/demand ANY fee, charge, remuneration, copay or any other cost from ME, I want to know what MY part is BEFORE any service is provided.
Informed consent on a purchase.
Everything else is fraud.
Correction to my post. I was still out $3000 for the meds.
“ready when they are notified of a patient coming in.”
When I had a heart attack last year I was in the ER just long enough to put me on life support after which I was immediately sent to get a heart cath and stent. I have glimpses of memory where there were about 10 people gathered around me. I believe this was when I got treated. The point is, I wonder what all these people were doing before I got there. I would not be alive if they had not been there.
It's like a roulette table where the insurer and hospital are the casino you're the chump.
I’m FINALLY getting much NEEDED endoscopy and colonoscopy because my health provider is switching to a 35 dollar co pay instead of 25 percent.
DO YOU KNOW HOW HARD it is to find out how much 25 percent of an outpatient hospital stay, an anesthesiologist, the doctor and God knows what else comes out to??
The hospital told me straight out they had NO IDEA.
And if a polyp was found or more than one and removed, well then it’s surgery and then that 25 percent could be 25 percent of 30,000 dollars!!
Set up both appointments for the first weeks of January.
Has Trump done anything to make my insurance company change something so much in the patient’s favor?
My guess was that people weren’t going for the tests and cancer costs a heck of a lot more than the tests, they’ve found.
It used to be if you went in just to see the nurse to get a shot, you would just pay for the shot. Then they changed it to an office visit so they could charge as if you saw the doctor.
They’ve also discovered PAs are much cheaper to pay than doctors and nurses are even cheaper. They’ve all but eliminated doctors here. Most clinics now only have nurses but we get charged as if we saw a doctor. What a scam and should be illegal.
Also, they’ll tell you Dr. XYZ is on the plan but they’re not and turn out to be a concierge doctor. So, where have all your premiums gone, huh?
Or if a new customer, they’ll bill you premiums for six months and when you try to get an office appointment you find out the paperwork somehow didn’t go through so you were never on the books. Again, where have all your premiums gone?
The health insurance business is a total scam.
Those bills will continue trickling in two years from now.
I broke my arm several years ago. Treatment involved putting a titanium rod in my arm and physical therapy afterwards.
The total bill from the hospital and physical therapy company was $32,000. The insurance company paid $1,200 for the whole thing. I guess the hospital and the pt company wrote off all the rest. My cost was $0.00.
Note: I no longer use this ins co as their rates got ridiculous after I got older. Some folks need to use their insurance a lot. For them, this insurance would be ideal. Some people, like me, don’t need to use their nearly as much. For them, a plan that costs much less but doesn’t pay for everything is the way to go.
DME items like CPAP equipment used to be a total scam, with insurance companies paying multiple times what you could buy online with a proper prescription, but the catch was that the online providers were not considered as preferred providers, and so if a patient purchased their equipment online even though the online equipment was way cheaper than the preferred providers, the patient ended up paying more than getting their equipment from an expensive preferred provider because the patient was reimbursed at a lesser rate ...
but that all seems to have changed, at least for CPAP equipment in my area, because the local provider i use now beats the pants off the online providers and have been forced by the insurance companies to lower their prices so much that they’re barely scraping by now ...
I agree. Which is why I don’t understand why people think involving third party payers even more in paying for health care is a good thing.
I get a kick that people are told they need a primary care physician so they don’t end up in the ER for non emergency care should they become ill. Ha! Try getting an appointment in short notice with your own physician. The only reason I have a primary care physician is so I can get refills on my blood pressure meds. Otherwise I would use the local walk in clinic. They at least post their prices up front.
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