Mt. Vernon Register-News

July 10, 2012

Did you know?

James B. Rippy

MT. VERNON — Did you know that a sizeable industry operates just reviewing medical bills? A lot of them operate on a contingency basis; some of them get paid a percentage of what they recover from billing mistakes, errors, omissions, fraud etc. I suspicion that a lot of us never even ask for details. We just figure that the insurance will pay it and go ahead and pay our co-pays or share without any detailed review. Take a look at the advertisement from one of the companies that were sent to me.

“Qmedtrix ( determines appropriate and reasonable reimbursement for medical services by identifying and correcting billing errors and instances of abusive or fraudulent billing. Our customizable services–medical bill review, re-pricing, abuse detection, strategic negotiation, payment recovery and tactical dispute resolution–work cohesively within your overall cost containment plan and provide for fair reimbursement for all parties.”

This is just one of many that specialize in reviewing medical bills. Some of the stories of errors, over charges and outright fraud are scary to say the least. I do not know about you, but going through a detailed bill for a hospital stay can really be confusing. An article sent to me written by Tara Siegal Bernard about an ex-emergency room nurse working as a medical billing advocate. She talked about her work helping people navigate the bewildering world of medical bills and insurance claims. Stories about a cancer patient who was charged $9,550.40 for a round of chemotherapy that he never received and another client of hers who was billed $11,000 for an 11 minute hand surgery does not give you a super level of confidence and a warm and fuzzy feeling about the accuracy of charges.

Even those folks with Medicare and a good supplement should not have a false sense of security that prevents them from reviewing their medical bills in detail. Most people just want to know how much they owe. Whether you have excellent coverage or a high-deductible, underinsured or not insured at all; you still probably want to know how they arrived at the charges. Are the charges reasonable? And are the charges for services actually rendered?

Here is what some folks had to say about hospital charges:

“Hospital care tends to be the most confounding, and experts say the charges you see on your bill are usually completely unrelated to the cost of providing the services (at hospitals, these list prices are called the ‘charge master file’). ‘The charges have no rhyme or reason at all,’ Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins Bloomberg School of Public Health. ‘Why is 30 minutes in the operating room $2,000 and not $1,500? There is absolutely no basis for setting that charge. It is not based upon the cost, and it's not based upon the market forces, other than the whim of the C.F.O. of the hospital.’”

And those charges don't really have any connection to what a hospital or medical provider will accept for payment, either. “If you line up five patients in their beds and they all have gall bladders removed and they get the same exact medication and services, if they have insurance or if they don't have insurance, the hospital will get five different reimbursements, and none of it is based on cost,” said Holly Wallack, a medical billing advocate in Miami Beach. “The insurers negotiate a different rate, and if you are uninsured, underinsured or out of network, you are asked to pay full fare.”

With so little pricing information available, expecting people to shop around for quality care at the lowest cost — something that's not always possible in emergency situations — is also asking a lot of consumers. “I have always found a bit cruel the much-mouthed suggestion that patients should have 'more skin in the game' and 'shop around for cost-effective health care' in the health care market,” said Uwe E. Reinhardt, a health policy expert and professor at Princeton University, “when patients have so little information easily available on prices and quality to those things.”

These are just some of the horror stories that get reported and when you reportedly have an entire industry surviving on just reviewing medical bills, something is missing. Can you think of any industry other than health care that has another industry that is paid to check that customers are being billed correctly? Medical billing mistakes can be costly if they go undetected. According to medical experts, 40 percent to 80 percent of medical bills contain errors, and Kaiser Health News estimates that nearly $68 billion in health care spending is lost to fraud and billing mistakes every year.

These statements just reinforce the need for a single payer system simplified to replace the broken system that we presently have described these in these articles.

 “With the exception of Medicare and Medicaid, experts say, the amount paid for services — or the price your insurers pay — is based on the market power of the insurance company on the one side and the hospitals and providers on the other, and the reimbursement agreements they ultimately reach. So large insurers that command a lot of market power may be able to negotiate lower rates than smaller companies with less influence. Or, insurers can place hospitals or providers on a preferred list, which may help bolster their business, in exchange for a lower reimbursement rate. On the other hand, well-regarded hospitals may command higher prices from insurers.”

Take a look at another excerpt from an article by Lynn Jeter sent to me that just adds to the need for a sea change in health care costs and method of payment.

“CNN reported on inappropriate charges by hospitals — a single toothbrush billed at $1,000; a single Tylenol caplet billed for $140 — coincided with Hospital Corporation of America paying out a record $1.75 billion dividend to their investors for 2009 results.”

“New York Times’ Jane Brody weighed in: ‘Errors are commonplace in hospital bills. A doctor may request a procedure or medication that is subsequently canceled or that the patient refuses, but it still goes on the bill. An entry error may result in a misplaced decimal point or an extra zero or two in the number of treatments, multiplying the cost 10 or 100 times.’

‘“Egregious charges like those described in the CNN report are much less of an anomaly than most payers think,’” said Mike Dendy, CEO of Advanced Medical Pricing Solutions, a privately held company based in Atlanta., that identifies and resolves systemic errors in medical billing. ‘The scope of the inaccurate billing issue is well documented,’ said Dendy, who established the medical billing auditing firm in 1995 and also serves as senior healthcare consultant for M&A Equity Advisors, a Miami-based mergers and acquisitions firm. ‘Whatever the causes for inappropriate and inaccurate hospital billing, the problem is universal and large in scale.’”

This is a relatively long column, but all we hear is how health care cost and accessibility divide our country. I wonder what would happen if our politicians directed their efforts to reducing the cost and improving the quality. Vote them all out and keep voting them out until the people are represented and not the special interest. Public financing of elections is a good start.