America's Fraudulent Healthcare Billing System. - Politics Forum.org | PoFo

Wandering the information superhighway, he came upon the last refuge of civilization, PoFo, the only forum on the internet ...

Provision of the two UN HDI indicators other than GNP.
Forum rules: No one line posts please.
#15053285
America's Fraudulent Healthcare Billing System.
https://www.straitstimes.com/opinion/fr ... are-system

Opinion

Where the Frauds Are All Legal
Welcome to the weird world of medical billing.


By Elisabeth Rosenthal
Ms. Rosenthal, a journalist and physician, is a contributing opinion writer.

Dec. 7, 2019
Much of what we accept as legal in medical billing would be regarded as fraud in any other sector.

I have been circling around this conclusion for this past five years, as I’ve listened to patients’ stories while covering health care as a journalist and author. Now, after a summer of firsthand experience — my husband was in a bike crash in July — it’s time to call out this fact head-on. Many of the Democratic candidates are talking about practical fixes for our high-priced health care system, and some legislated or regulated solutions to the maddening world of medical billing would be welcome.

My husband, Andrej, flew over his bicycle’s handlebars when he hit a pothole at high speed on a Sunday ride in Washington. He was unconscious and lying on the pavement when I caught up with him minutes later. The result: six broken ribs, a collapsed lung, a broken finger, a broken collarbone and a broken shoulder blade.

The treatment he got via paramedics and in the emergency room and intensive care unit were great. The troubles began, as I knew they would, when the bills started arriving.

I will not even complain here about some of the crazy high charges: $182 for a basic blood test, $9,289 for two days in a room in intensive care, $20 for a pill that costs pennies at a pharmacy. We have great insurance, which negotiates these rates down. And at least Andrej got and benefited from those services.

What I’m talking about here were the bills for things that simply didn’t happen, or only kind-of, sort-of happened, or were mislabeled as things they were not, or were so nebulously defined that I couldn’t figure out what we might be paying for.

To be clear, many of the charges that I would call fraudulent — maybe all of them — are technically legal (thanks sometimes to lobbying by providers), but that doesn’t make them right. And no one would accept them if they appeared on bills delivered by a contractor, or a lawyer or an auto mechanic. There were so many of these charges that I came up with categories to keep track of them:

1. Medical Swag

In the trauma bay, someone slapped a hard brace around Andrej’s neck until scans confirmed that he had not suffered a grievous spinal injury. It was removed within an hour.

The medical equipment company that provided that piece of plastic billed $319. Our insurer paid $215 (90 percent of its discounted rate of $239). We were billed $24, our “patient responsibility.”

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.

At least with swag, you get to keep it. My husband’s hardly worn neck brace didn’t even come home with us as a souvenir.

2. The Cover Charge

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 when they are performed in an emergency department?

Despite scrutiny from researchers about whether trauma fees are deserved, trauma activation fees have only grown in size, 15 percent annually in recent years, and can reach into the tens of thousands of dollars. (On average, Medicare pays a fee of about $1,000.) Some have likened trauma activation fees to a cover charge for being wheeled into an E.R. with major trauma. But does a cover charge typically cost more than the meal?

3. Impostor Billing

We received bills from doctors my husband never met. Some of these bills were understandable, like for the radiologist who read the scans. But others were for bedside treatment from people who never came anywhere near the bed to deliver the care.

Andrej had a small finger fracture with a cut that needed some stitches, which a resident, a surgeon-in-training, sutured. But the $1,512 billed came in the name of a senior surgeon, as if he had done the work.

Physicians and many other health professionals are allowed to bill for the work of “extenders” — stand-ins with less training who see patients and work under the supervising doctor. These might be residents, physician assistants or nurse anesthetists, for example. For billing purposes, this allows the senior providers to be in two, three, sometimes more than half a dozen places at once, often even when they are physically miles away.

The resident did a fine job on my husband. But if an assistant did the work, shouldn’t it be billed for less? At law firms, the hourly rates for paralegals and junior attorneys are lower than those for partners.

On a website called Clinical Advisor, a reimbursement expert himself seemed to wonder at the profession’s luck that such billing is tolerated: “I hear people ask, ‘How can I do that? The doctor never saw the patient, never had any interaction with the patient and yet I can still bill this service under the physician?’”

4. The Drive-By

The day before Andrej left the hospital, a physical therapist visited and asked a few questions. From that brief encounter, the therapist noted “ambulation deficits, balance deficits, endurance deficits, pain-limiting function, transfer deficits.” That translated into a bill of $646.15 for what was recorded as a P.T. evaluation “1st session only (billable).” He said he was there for 30 minutes, but he was not. He said he walked Andrej up 10 steps with a stabilizing belt for assistance. He did not. There was no significant health service given. Just an appearance and some boxes checked on a form. It’s a phenomenon called drive-by doctoring.


More shockingly, the drive-bys continued at our home, presaged by a call on Andrej’s cellphone a day after he was discharged. A physical therapist from a private company wanted to visit him for at-home therapy. In his discharge instructions, no one had mentioned this service, and his injury was clearly too fresh to benefit. She came. She didn’t know which body part had been injured and concluded he was in too much pain to participate.

The same company called twice more the following week to schedule visits. By the third time, I told Andrej not to open the front door. Nonetheless, our insurer was billed — and paid — for three visits.

It’s as if Alexa noticed that my dishwasher makes too much noise (it does) and took it upon herself to send over a repair guy. But if I turned him away at the front door, saying I’m O.K. with the racket (I am), would I still be billed for the visit?

5. The Enforced Upgrade

One Monday when Andrej was in pain and out of pills, the trauma doctor suggested we meet in the emergency room, because the trauma clinic was open only from 8 to 10:45 a.m. on Wednesdays and Thursdays.

So we met the trauma doctors in the E.R., and they talked to Andrej, who remained in his street clothes. They gave him a prescription. Because the interaction — which could have happened in the lobby — happened in the E.R., it resulted in an E.R. visit charge of $1,330. But when the trauma clinic is open less than six hours a week, billing for an E.R. visit that doesn’t tap into any of the emergency room resources feels like a scam. Is an E.R. visit determined by the content of the services rendered, or merely by the location?

Andrej had a similar experience when his broken finger was treated with a plastic splint that folded over his fingertip. He complained because the upper layer pressed on the fracture. At a follow-up visit, someone took a pair of scissors and cut off the upper half of the splint and taped the lower half back in place. That translated into a $481 charge for “surgery,” in addition to the $375 charge for the office visit and a $103 facility fee. Doesn’t surgery, by definition, involve cutting into flesh or an animate object — not a piece of plastic?

Sure, it sounds fancy to upgrade a meeting to an E.R. visit, or to call the tweaking of a splint “surgery,” but if an airline overbooks my flight and puts me on another flight where the only seat available is in first class, it does not charge me for the more expensive ticket.

My insurer paid for most of these questionable charges, though at discounted rates. But even a discounted payment for something that never really happened or didn’t need to happen or that we didn’t agree to have happen is still, according to common sense, a fraud.

Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because it’s not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern about your well-being, as one benefits manager enlightened me: They’re “too big to care about you.” Electronic records, which auto-fill billing boxes, have probably made things worse. For example, the birth of a baby boy may automatically prompt a bill for a circumcision; having day surgery may prompt a check for sedation.

So what is the appropriate payment for swag I didn’t ask for, outrageous cover charges, stand-in doctors, drive-by visits and faux surgery? In some cases, zero; in others, far less than was paid. And yet, these are all everyday, normal experiences in today’s health care system, and they may be perfectly legal. If we want to tame the costs in our $3 trillion health system, we’ve got to rein in this behavior, which is fraud by any other name.

Elisabeth Rosenthal, a former New York Times correspondent, is the editor in chief of Kaiser Health News, the author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” and a contributing opinion writer.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips. And here’s our email: letters@nytimes.com.

Follow The New York Times Opinion section on Facebook, Twitter (@NYTopinion) and Instagram


https://www.nytimes.com/2019/12/07/opinion/sunday/medical-billing-fraud.html
#15053287
The cure for that disease is single payer.

It's the only cure, no variation on medicare will fix that, and some could make it worse.

Hospitals are fighting for survival. A few close every year, and that becomes a life and death problem in rural areas.
#15053365
I think by "single payer" u mean that the government pays for everything. Isn't this a communist system? And if indeed it is a communist system, would it really work better than the present Fraudulent billing system or will the entire system collapse just like the USSR in 1989 or so (Berlin Wall fell down) ?

Many 3rd world countries also have a rudimentary public healthcare system, if any because the people are so poor that the only medical groups that visit the rural areas are medical and religious charity groups... Many of these poor countries are monarchy or ex communist States, so u get the drift. What makes u think that single payer will work well for a country as large as America, except if America becomes like China, under authoritarian rule, widespread population surveillance and social credit system etc.
#15053400
kazenatsu(PF. com) wrote:To be fair, some of that is due to the legal liability system. In many ways it's practically like a lottery. And someone has to fund that lottery. If you want to talk about the problem of high prices, one of things that has to be addressed is the dysfunctional court system that handles things when something goes wrong and there's a lawsuit. Maybe what is needed is to set up a special court system for handling medical claims, with neutral impartial medical experts on hand to properly judge the issues.

Whilst the dysfunctional court is to be blamed, the government is more so to be blamed for poor public policy and education.

A recently published Swedish study (Low-Risk Diet and Lifestyle Habits in the Primary Prevention of Myocardial Infarction in Men: A Population-Based Prospective Cohort Study(2014)) revealed that "Men having all 5 low-risk factors compared with those with 0 low-risk factors had a relative risk of 0.14 (95% CI: 0.04 to 0.43)." https://doi.org/10.1016/j.jacc.2014.06.1190

This shows that vast majority of serious medical crisis like heart attacks are vastly preventable by ~79% (according to the study) if citizens made much greater efforts to adopt the healthiest lifestyles possible and accept personal liability for such crises should they continue to adopt unhealthy lifestyle practises through increased medical insurance premiums etc.

Thoretically, this would reduce national healthcare expenditure by at least 79% (supposing the 5 healthy lifestyle factors were further examined and made more precise) and thus making a nationalised healthcare system like the NHS a conceptual possibility in America (a much bigger country, geography and population wise) and still maintain treatment standards, rather than become bankrupt overnight due to over consumption of services due to irresponsible lifestyles causing an excessively high disease workload (as is the status quo situation now).

As I have always said, medical disease is like a fire, best prevented. Once the fire has smothered unnoticed for a while or broken out on a big scale, the damage is usually very significant and irreversible and even the treatment (water and chemicals used to put out the fire) will have very significant long term side effects and added damaged caused. An ounce of prevention is certainly worth much much more than a pound of 'cure'.

Isn't oil and electricity bought and sold like ev[…]

@Potemkin I heard this song in the Plaza Grande […]

Russia-Ukraine War 2022

The "Russian empire" story line is inve[…]

I (still) have a dream

Even with those millions though. I will not be ab[…]