What's wrong with US medical care?

Dear Dr. [redacted],

Last September I visited your office in order have a few medical concerns addressed.  During the appointment, you wrote me a prescription and also took a look at the plantar wart I had on the ball of my left foot. You then used a spray canister to apply liquid nitrogen to my foot. The sum total of these two services took under twenty minutes of your time.

During the same appointment, you also treated my son, Alexander, for an ear infection, which added at most ten minutes to our appointment time.

When I received the bill from your office, I was stunned.

My insurance had been billed for three charges:

My son's care: $152.19
My care: $173.55
AND
A "surgery" for wart removal at an additional $220.72.

The total amount for the thirty minute appointment was $546.46

Fortunately, we have insurance through my husband's employer and all but $225 of this total was paid for by Blue Cross.  I also understand that you are a doctor and billing is neither your responsibility nor your expertise, but after repeated attempts to have my bill reduced to a more reasonable amount through your office staff, they sent me to a collection agency instead of budging even ONE dollar on the total amount.

Here's the thing, Doctor.  I HAVE the money.  I don't care AT ALL about the money.  It's the principle.  My wart removal was billed as a "surgery" and I think we can both agree that what you did was not even remotely close to performing any kind of surgery.  In fact, I would venture to guess that your liability insurance doesn't even cover you for "surgeries" at the Vancouver Clinic family practice offices.  But because of the way it was coded and billed to my insurance, it wasn't a covered expense and I am being billed out of pocket for it.

I also know that before ever stepping foot in your office, I signed a document saying that I would be ultimately responsible for any and all charges for my medical care.  I understand that I'm responsible to pay for this.  I get that.  I'm not denying my responsibility in the matter.

But because as a patient I HAVE NO CHOICE but to sign that document accepting responsibility for the charges, I basically allowed you and your medical practice to charge me ANYTHING YOU WANT for my medical care.  I have zero say in the matter because by the time the treatment has been provided, I already owe the bill, no matter what it is.  I also had no way of refusing service ahead of time based on cost because you are a doctor, not a medical billing specialist and you were unable to provide me with an estimate.  In hindsight, no person in her right mind would chose to spend $225 for a service that basically amounted to the same treatment I could get from a box of Wart-Be-Gone at the drugstore for $10.

Do you see the problem inherent with this system?  How absolutely detrimental it is to consumers?  Even those like me who possess not only the ability to read complex medical billing documents but also both insurance AND the resources to pay for excess charges.

Basically, I signed a document that allows you to charge me whatever you want for my medical care.  So in theory, you could have charged me $1000 for that thirty minutes of your time and I would still be responsible for it. 

That's wrong no matter how you look at it and the fact that your staff was rude and unaccommodating and in fact HUNG UP ON ME when I tried to push the matter politely only adds to my dissatisfaction with your practice.  

I have offered to pay $100 to settle this bill.  I think that amount is MORE than fair compensation for your time and service.  I'm asking you to either resubmit the charge to my insurance company as a NON-SURGICAL code or have your billing department reduce my bill to $100.

Sincerely,

Amanda Mandajuice

PS - I still have the wart.

Comments

[Carrisa]

So um if you want to email me I'll tell you how you can get out of paying this bill.

[jonniker]

Yeaaaah. This is the same conversation I had last year with the podiatrist who charged me $95 -- NINETY FIVE DOLLARS, AMANDA -- to wrap my foot in an ace bandage with a cookie at the sole. It took a total of 30 seconds. I'm not kidding.

They called it something very special, but what they did not realize was that I did that at home myself during the times I didn't see them, with supplies that cost me a total of $20.

OH MY GOD.

[Jessica]

I work for a very large health insurance company and deal with doctors who are trying to get their claims paid several times a day. In fact, I only work with doctors. They can bill their claims however they like, and I can tell you right now that if it's between billing a "produre performed in an office" or a "surgery performed in an office", they will go for the surgery. I probably see "administration of an injection" billed twenty times a day and it's usually billed at over $40! $40 for a nurse to stick a needle in me. 40 bucks for two seconds of effort. I'll pay for the damn needle and vaccine but come on now... Depending on the insurance plan it sometimes is considered inclusive to the visit, and in that case it is written off and they can't bill you. A lot of the time though, it's just not covered, and then the provider can bill you full price, even if it is more than the insurance company would allow. There's amounts billed and amounts allowed, the allowed always being smaller. I would consider shopping around for doctors. I pretty much hit the jackpot with our family practice. They are amazing and helpful. Our insurance company wouldn't pay for my son's five year check up until AFTER his fith birthday, but I needed his checkup for school to be done right then. Three nurses spent ten minutes finding a way to code it so it would be paid for. I went to them for my obstetrics with my youngest and afterwards at his checkups the first couple months, if i needed anything, they'd take care of it, no seperate office visit charge. Recently I took my oldest in based on some autism spectrum behaviors and a developmental delay diagnosis from his school. The doctor could have easily pushed me to going to a private facility to get him evaluated, but instead personally cassed two mjaor universities and got us in with both. Because it will be cheaper. The bottom line is, to me anyway, making sure to the best of their ability that an insurance will cover something should be top priority to providers. Billing patients gets them no where most of the time, or delays payments by MONTHS. I don't know if any of that helped, but you must be an advocate for your own health and health care and I am glad you called them and pushed the issue. Have you called Blue Cross? Sometimes they will advise you of dxs or procedures that the provider would bill on a corrected claim to get the service covered.

[Jessica]

Yeh I messed all sorts of words up in there. I really can spell and type. really.

[Serror]

Oh yeah. That is total BS. Not a surgical procedure!

[Allison]

I probably couldn't have more opposite political views than you, but I totally agree with you in this case. If the health care "market" is supposed to work, then consumers need to be able to get an estimate ahead of time. Of course this will not work in all situations (like emergency care), but for many services it would help to shop around.

[Debra]

Hey I had a similar problem with the local hospital for the emergency room. My youngest son ran into a doorjam and cut the top of his head--one inch in length. It didn't bleed, it oozed. At 8:30p.m. I had no options. I took him in and they glued the cut shut. A few weeks later I got the bill $775 from the hospital. My husband and I started to refer to it as the $800 glob of glue. Then another few weeks went by and a second bill for $450 appeared from the physicians office. When I called I was informed that the first bill was for the room and the second was for the actual person. And, we wonder what is wrong with the medical profession. By the way, we have insurance so we ended up paying $100.

[lindsaywillman]

Consider yourself lucky if you don't receive a letter after this stating that they can no longer see you as a patient because you're too needy.

Happened to me after I complained about the billing of my appointment.

[Jessica D.]

As a professional coder, I can tell you that offices bill all kinds of stuff just to get paid. Others bill inappropriate codes out of ignorance. Either way, there are criteria to meet prior to assigning a code to a service. HOWEVER, if the documentation doesn't support the code chosen, the code is invalid and not billable. Demand a copy of the medical record and submit that directly to your insurance with a letter of dispute. Inappropriate coding is FRAUD. The American Academy of Professional Coders (AAPC) is committed to integrity in coding. Find a certified professional coder (CPC) in your area and ask for a review. Your clinic should have a compliance officer to review such matters in-house, and bringing this matter to his/her attention might be another option for you. It's an uphill battle, but right is right, right?
Do post the conclusion when it arrives!

[Jessica D.]

Edited to add: Fraud is committed when the provider knowingly, (maliciously?) bills a code strictly for purposes of receiving payment. Billing for a more expensive procedure, in the interest of payment, is obvious fraud.
If a procedure is not covered by your insurance, it is inappropriate to "fudge" records or change codes just to get something paid. No matter how good the intentions are, this scenario also constitutes fraud.
As Jessica described above with her injection example, "unbundling" is exactly what it sounds like: billing separately for items that should be billed as a bundled unit. Unbundling is fraud.
As Debra described, there are "professional" fees (for the provider of the service) and there are "technical" fees (for the room or equipment, as in a hospital setting.) (For example, two days in the hospital might have technical fees for the room and any tests performed, as well as professional fees for any specialists who visit.) When these items occur in a particular setting, they are called "global" fees, which include both the technical and professional components. There are rules that apply to determine appropriate use of codes.
Professional coders worth their salt will follow these rules when billing. They'll also provide the documentation that supports the coding chosen and walk you through the process, if necessary.
As I explained above, when in doubt, request a copy of the medical record/documentation and request a review by a professional coder. An office secretary or personal assistant often lacks the technical knowledge required for proper coding. If your doctor's office or clinic doesn't resolve the situation to your satisfaction (either by recoding or explaining the coding used), go to the compliance officer or board for appeal. You also have the option to supply the documentation to your insurance company for an appeal.

[A'Dell]

I am right there with you. It's just UNBELIEVEABLE what happens to people.

Although, I have to disagree with you on one part - I think it is absolutely the Doctor's responsibility to know what things are going to cost and how they will be billed. It is THEIR practice. They are in charge and the responsible parties.

I have taken to asking for a written estimate of services before I let them do anything. And they always look at me like I'm nuts.

I hate it. It's so ridiculous and the nurses and staff are ridiculous.

If I were you I'd report the office to the state medical board for refusing to provide an estimate of services and also that you're unsure if he's licensed to perform surgeries in his practice. You could also take it up with your insurance provider - I'm sure they'd LOVE to know if something was billed at a higher rate than it should have been.

In any case though, it sucks. Sucks bigtime, is too expensive, doesn't work, people get crappy care.

One of my hugest pet peeves.

[Lisa]

Go Amanda! I hope you don't mind if I keep and use this for myself one of these days.

[Jimmie]

I do have to say that most physicians are able to do "in-office surgeries" in their clinic. Surgery is a loose term, however...it doesn't mean use of general (or even regional) anesthesia, and it usually doesn't involve much more than a biopsy, nail removal, wart removal, etc. Those are generally legitimately performed and billed as surgeries. HOWEVER...using a can of liquid nitrogen is NOT a surgery, for pete's sake. Wart removal surgery should involve an injection of lidocaine and the use of a scalpel!

Definitely take this up with whomever you can to get it resolved.

[Danell]

I'm sorry A'Dell, but as a medical professional myself, I can tell you right now that I am NOT going to try to learn the ins and outs of insurance and billing on TOP of earning a medical degree. I mean, have you read these comments from some of the insurance folks? You make it sound like it's as simple as memorizing a menu, when if fact IT IS NOT. I mean, the American Academy of Professional Coders? The insurance profession is just that nowadays, its own SEPARATE PROFESSION. (I certainly don't want my doctor having to learn all of that when I'm more interested in them keeping up on their medical knowledge...) And THAT is part of the reason that medical services cost what they do. That $40 injection? The doctor isn't pocketing $39.50 of that...the office has to pay those nurses, the receptionists, insurance premiums, AND THE INSURANCE PROFESSIONALS to properly deal with insurance CODING.

[David]

If I call opposing counsel and leave a 7 second voicemail message, it costs my client $45.00. Welcome to the world of overpaid professionals.

Just pay the damn bill which has now been referred to collections. You have become "that crazy lady who keeps calling to complain." The doctor is not going to suddenly admit that he made a mistake that persisted, against your numerous protests, to the point that a collection agency became involved.

[Amy H]

I hope you sent this letter to the office for real. That is total BS.

We made the mistake of thinking that being "double covered" (insured by both my company and my husband's company) would make our lives easier and ultimately cost us less when we had a baby. We were wrong.

Our doctor charged my insurance, which is considered secondary since my birthday is later in the year than my husband's birthday (what? how do they come up with this stuff?) rather than my husband's insurance for my son's care in the hospital right after he was born. Naturally, my insurance declined the claim since they were not the primary coverage so rather than going back and looking at the forms I filled out...my doctor sent me a bill. When I called to tell them they simply need to charge my husband's insurance company first...they said they understood and agreed to re-submit the charges. SIX MONTHS LATER we got another bill for the same amount. I called again...told them to charge my husband's plan again...and this time they said that it may be too late since it was past 90 days from the procedure. At that point my head almost exploded because as a consumer there is NOTHING I can do about my doctor's billing department being illiterate. I finally got a collections letter and went a little nuts and they straightened it all out.

But damn. That is a lot of trouble for a billing error.

[Jessica]

Danell, I am not opposed to paying what is right and fair and certianly understand the doctor doesn't pocket every payment. I still think $40 for administering an injection is ridiculous and you won't change my mind about that. You are possibly a great provider, but I speak to several on a daily basis who scream at me because they want "their money" (keep it in mind this is usually some sort of billing company in another state) and are livid because our company won't allow an assistant surgeon for the simplest of procedures. I am in no way saying insurance companies are guiltless either. They frustrate me as much as any physician's practice ever has. And I work for them.

[taylor k]

agreed! i am in the same boat now!

[Mitzi]

Cool. I hope you really sent that to the doctor and you're not just venting on your blog. I love it! I may need to use some of your wording one day!

[Alias Mother]

Oh, nothing gets me worked up like our crippled, stupid, expensive, fraud-ridden health care system.

My doctor has a price list of common procedures that they can produce upon request--along with a sign in the office stating they are happy to do this. I live in an area where a lot of folks are self-employed (read: uninsured), so it's necessary. Danell, you and other providers could easily ask your staff to take on this project (maybe a week of sporadic work?), type up a list that is reviewed annually, and have it available. Look at it this way: who in their right mind would drop off their car at the mechanic, say, "Do whatever you think," and NEVER ask for an estimate up front? Medical procedures are 1,000 times more expensive than car repair and I think providers should be able to tell you what something is going to cost.

A few providers in my state have decided to forgo the broken system altogether. They accept no insurance, bill you a flat fee for an office visit, a fixed fee for a procedure, and everyone leaves happier. I hope one opens an office near me, because I am so there. It more accurately reflects how my family uses health care and makes much more sense than the $800 I/my company is billed per month for coverage, even though my family only uses a doctor a handful of times a year.

[Laura (not the usual one that comments here)]

OK, I'm bracing myself to be ripped apart here, I know this, but I'm.... going to side with David on this one. There's a reason doctors go to medical school, and lawyers go to law school. Are you ready for this? The reason they put themselves through all the torture of that higher education, and incur the costs of all that education is TO MAKE MONEY.

Let's consider the $40 injection everyone keeps talking about. Sure, the nurse is in the room with you for MAYBE 30 seconds, but here's some of what that 30 seconds entails (I know I'm missing stuff here, but this is off the top of my head):

1. the cost of the syringe
2. the cost of the medication in the syringe
3. the cost of the "extras" (bandage, antiseptic, latex gloves, etc.)
4. the nurse's hourly pay
5. the nurse's benefits package
6. malpractice insurance
7. liability insurance
8. rent/lease on the space the doctor's office is in
9. income/benefits for the following support staff: receptionist, billing specialist, nurse's aid (if there is one), office manager
10. taxes
11. water, power, gas, etc.
12. the little bit of money, resulting from this shot, after the insurance company pays their "negotiated price" that the doctor would like to pocket from his/her business (keep in mind that he/she is also most likely paying back hundreds of thousands in student loans).

All of these things are rolled into the price of that "$40 shot".

Now, I know there's a lot of fraud and overcharging in the medical profession, and it's a mess, but doctors have a LOT of overhead to cover, as well as being expected to be paid for their YEARS of schooling and expertise.

[Amy]

I had a similar experience at the Dentist. I didn't even see the dentist and I was in the chair for exactly 4 minutes 15 seconds (I had a clock in front on my face so I kept up out of boredom). The hygienist told me that the dentist had overbooked and I would need to reschedule for my filling. They had the nerve to send me a bill for $50! WTF??? I presented myself front and center at the dentist office and DEMANDED to know (in my outside voice) WTF WAS UP WITH THIS??? That I had not even seen the dentist and they had another thing coming if they thought they were going to screw me out of my hard earned money. They wrote the charge off.

[Teri]

I'm just shocked that the Dr. saw both you and Alex in one appointment. Currently my Dr. will only see and talk with you for exactly what you indicated the need for your appointment was. If I call and make an appointment for a sore throat and then try to talk to him about anything other than the sore throat I am told that I will have to make another appointment. Now of course I only have a $15.00 office visit co-pay, however it can also take up to two or more weeks to get an appointment with him. I got lucky last week when I was able to get into him the same day due to a cancellation, however I scheduled the appointment for an issue with my leg and when I asked to get a refill on a previous prescription and about a dark scabby area of skin I was told that I would have to make another appointment. Mind you that the original purpose of the appointment took all of 5 minutes and to write a prescription and look at this spot wouldn't have taken more than another 5, yet now I have to wait until March 24th at 2:45 to have the spot looked at, sure hope it isn't skin cancer. They do offer a call in prescription refill service, however when I tried that I was told that it was time for the Dr. to evaluate my continued use of that particular medication so I would have to make an appointment. I then called the office back to add needing to talk to him about the prescription refill to my appointment about the skin issue and she indicated that I was alloted enough time to discuss the initial complaint so I would have to make another appointment. I was furious. I decided to ask when the next available appointment would be and she indicated March 24th at 3:00, I thanked her and hung up. I called back 5 minutes later and cancelled my 2:45 appointment. When she asked if I would like to reschedule I told her that I only had enough time alloted to call and cancel so I would have to call back to get another appointment. I waited another few minutes and called back, I said I needed to make an appointment with the Dr. as soon as possible and was told that she had an appointment for March 24th at 2:45 available. I told her that I would take it. When she asked what I needed to be seen for I told her for a dark scabby area of skin and a prescription refill evaluation. All is good now...seems that they really did have enough time alloted for both issues on the very same day at the very same time. Tell me that this isn't right up there with the best of the idiotic world of medical care!

[Danell]

Thanks Laura! Woot!

[Jessica]

Laura, not true. THe administration of the injection fee is often billed seperate from the injection itself. Hence my issue with it. But there are a million other examples of piddly things being billed seperately out there so let's forget about the damn injection administration, eh? Chalk it up to health care is expensive.