How to fight an outrageous hospital bill in 10 easy steps. First: Be a doctor or nurse. Then learn about upcoming….OR BETTER YET, SEND THE CLAIM TO AMPS
Editor’s Note: This Wall Street Journal article was sent to us by our friends at AMPS
Wall Street Journal
As a doctor and a lawyer, I like to think I’m pretty good at navigating the health-care system. So when my wife and I found a large swollen bruise on our 3-year-old son’s head more than a week after he had fallen off his scooter, I was confident we could get him a CT scan at a reasonable cost.
We live near one of the top pediatric emergency rooms in the country. The care was spectacular. My son was diagnosed with a small, 11-day-old bleed inside his head, which was healing, and insignificant.
I was proud to see the health-care system working, to see academic medicine working, and most of all to see my son run as fast as he could out of the ER two hours later.
Then the bill arrived, and you know where this is going: $20,000. Our insurance had already paid $17,000, and we owed $3,000 out-of-pocket. What for? Among the items listed on the printout was a $10,000 charge for a “trauma team activation.” This made me want to give consumers some very simple tips on how to fight their health-care bills, so here goes:
1. Get yourself a job as a doctor or nurse. I’ve served on trauma teams in two of the busiest hospitals in New York City, and I know what a trauma-team activation looks like: doctors, nurses and residents running and yelling, IV lines, monitors. You know one when you see one. Nothing like that happened around my son. So I picked up the phone and told the hospital that the trauma charge was a mistake.
The billing agent explained that it was hospital protocol to call a trauma team when there is internal bleeding in a head injury. I argued, correctly, that it wasn’t clinically indicated.
2. Have or gather the legal knowledge to know when you are being lied to. The hospital billing agent wasn’t a physician and couldn’t refute my clinical judgment, so she told me it was “county protocol” to call a trauma in such cases. This was a bluff, meant to get me off the phone by hiding behind regulations, a very effective tactic used by hospital administrators.
I called her bluff and said if she could show me the county regulation requiring a trauma team for an 11-day-old head injury, I’d happily pay my bill. She said she’d have the head of emergency services call me.
3. Have the resources to pay huge bills up front while you wait the months it takes to correct billing errors. Two weeks later, the physician head of emergency services called. He was professional, knowledgeable and in agreement that I should not have been billed for the trauma activation. He’d call the billing team to tell them so.
A week later, the hospital wrote to say that they were delighted I’d had the chance to speak with the head of emergency services, but the billing department had determined that the $10,000 charge was accurate.
4. Understand that only the billing department, not the physicians, decides what is billed. The hospital we visited is a level-one trauma center, so it will bill for a trauma activation at every possible opportunity. It’s how any sane person would run such a cost-intensive business. Hospitals will always “upcode”—bill for as intensive a level of care as they can legally get away with.
5. Know where the hospital billing managers go to decide what kind of upcoding they can get away with.
Most hospital billing guidelines, whether for Medicare or private insurers, are derived from a several-thousand-page manual published by the Centers for Medicare Services called the Medicare Claims Processing Manual. You can access it online at CMS.gov, although it is impenetrable. But here’s a secret: There are lots of blogs out there written by the hospital coders that do the billing, and they blog about how to ensure a hospital can make their bill stand up to the payers—i.e., insurers—whose job is to negotiate the bill down.
6. Google like mad. Thirty minutes of informed search revealed that in order to bill for a trauma activation, the Medicare Claims Processing Manual, or MCPM, requires that the trauma team be activated either by EMS—an ambulance—or by an another hospital transferring the patient. This makes sense. If you want to bill $10,000 for a trauma team, you can’t unilaterally decide that the patient required a trauma team. That would be like a supermarket being able to require you to buy $10,000 worth of chicken because they decide that’s what you’re hungry for.
7. Have the combined medical and legal knowledge to understand the implications of the coders’ rules. Since we drove my son to the ER, the trauma-activation requirement was not met. This was a huge failing by my insurance company when it initially allowed the charge. Their adjusters should know that a payer shouldn’t pay for a trauma activation unless there is documented evidence of an EMS or outside hospital activation.
I called the billing supervisor at the hospital. He was very friendly and professional and told me why the bill was valid.
8. Unleash the hounds. I let the billing supervisor speak for a moment, and then cut him off using the ammo I had acquired from billing-coders’ blogs. “You billed a G0390 for trauma-team activation. But chapters 4 and 25 of the MCPM require there be EMS or outside hospital activation if you are billing a G0390. There was no such activation here. So here is what I need you to do: Remove that $10,000 charge and reissue the bill.”
He was silent for a moment. And then he said, ” Let me talk to my supervisor.”
9. Be graceful in victory and realize you got lucky. To the hospital’s immense credit, they sent a refund to our insurance company and reissued the bill without the $10,000 trauma activation. They could have refused. What would my recourse have been? To hire a lawyer? Try to interest my insurer in fighting over a measly $10,000 charge? That is a tiny line item in their book of business.
I believe in free-market solutions almost as strongly as I believe in abiding scientific principles such as relativity. I think the quality of care in the U.S., if you have the right insurance, is the finest in the world. As a biotech executive, I think the U.S. is responsible for driving more global medical innovation than any other nation.
But our actual delivery system is just a mess. The new Affordable Care Act is just “a complex and somewhat ugly patch on a complex and somewhat ugly system,” as Princeton economist Uwe Reinhardt put it. Nothing will change until we shift incentives away from overuse and upcoding, but both Democrats and Republicans have spent more of their time attempting to scare their constituencies than they have deeply examining incentives and proposing any solutions—free market or otherwise. Which leads me to:
Step 10. Skip medical school and law school and get your child a helmet.
Dr. David is co-founder and chief strategy officer of Organovo Inc., a biotech company in California.