If there’s one issue on which there is consensus in this drawn out, drama-laden pre-election time it’s that our healthcare system is seriously broken. Whether voters are for an incremental approach to reform, a course correction for the Affordable Care Act, or behind a magic bullet Medicare For All plan, they agree that the situation is a mess on many levels, often resulting in catastrophic outcomes or financial ruin.
We all have illuminating stories to tell. Mine is specific to the high cost of healthcare and a suspicion that Medicare is being seriously ripped off.
Not long ago I visited a specialist’s office to relieve a blocked ear that resulted from flying with a cold. A physician’s assistant looked in my ear, declared me free of fluid or infection, and bizarrely suggested I have an MRI to rule out a brain tumor. She then prescribed steroids. I ignored her advice, tore up the prescription, and three days later my ear popped itself open.
For that short visit I was billed $38. Medicare paid the remaining $305.
Astounded by a charge of $343 for a brief office visit with a PA, not the doctor I’d booked the appointment for, I called the billing office where I was seen to query the bill. I asked specifically who decided the billing codes, what the criteria were for coding, and why I was billed the same rate for a PA as for the MD I didn’t see. No one could answer my questions. I then called the physician’s office, which referred me back to the billing office.
I wrote to the billing office and soon received a troubling response from the Director of Customer Services, which I felt compelled to answer. My letter speaks for itself.
“Thank you for your response which attempted to explain your cost policies,” I wrote. “I do not wish to beat a dead horse, but I must reply for reasons which are obvious.
“You stated that ‘when it comes to pricing, rates are set by a board of directors annually.’ I fail to see how a hospital board can arbitrarily set prices, or codes, for services covered by Medicare, a federal program that establishes reimbursement standards for anyone whose primary insurer is Medicare.
“You also refer to ‘complexity levels based on the nature of your condition, paperwork, examination and counseling time.’ To be clear, my visit was hardly highly complex. I had a blocked ear, not a perplexing condition. My visit required no paperwork beyond a chart note and a brief examination which simply involved looking in my ear. No sophisticated equipment or counseling was necessary.
“You also stated that costs included “caregiver’s time, space where services were provided, equipment, supplies and medications used.” Let me be clear: No equipment, supplies or medications were used. My visit was a half-hour or less. Am I to believe that my cost included a fee for using an examining room? What’s next? An elevator fee? Restroom fee? Assessment for corridor or cafeteria space?
“You stated that yours is a ‘charitable healthcare organization’ that cares for people regardless of their ability to pay. While that is admirable, I do not expect to be assessed a charitable giving fee. I will decide, not your institution, how much and to whom my philanthropy goes!
“Equally, I do not expect to involuntarily subsidize ‘physician training’, ‘conduct of medical research,’ or ‘specialized services using the newest technology.’ If I wanted to support those goals, I would do so in the form of a dedicated donation. I am astounded that patients are unknowingly assessed fees for these things.
“How interesting that in listing your goals you state that you want to ‘have fair patient prices that enable [you] to advance health through research, education, clinical practice and community partnerships.’ Note the rank order of priorities in that list, and the absence of ‘quality patient care’ as the first priority.
“My experience doesn’t meet all the standards of Medicare fraud and/or abuse as articulated by the federal government and healthcare watchdog groups, but it comes very close to two of them: “Charging excessively for services or supplies” and “upcoding” or incorrect billing.
“I’m sad to say that I don’t expect this letter to change anything with respect to billing at your facility, but I do hope you and your colleagues will reflect seriously about the issues it raises -- and that you will be “fair and balanced” as well as transparent, when addressing costs incurred by Medicare and the seniors served by that program. It is telling that I received a 10% cut in my Social Security this year due to the increased costs of providing Medicare. No surprise there now that I’ve seen your billing criteria.”
According to www.CMS.gov , a government agency dealing with healthcare fraud and abuse, “No precise measure of healthcare fraud exists, but those who exploit Federal healthcare programs can cost taxpayers billions of dollars.” CMS defines abuse as “practices that may directly or indirectly result in unnecessary costs to the Medicare program.” Examples of abuse include “charging excessively for services or supplies and misusing codes, or “upcoding.”
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