When my son Jack was 5 years old he threw caution to the wind and drove his Power Wheels Jeep, full speed, under a hammock. The hammock caught his front 6 teeth pushing them completely up into the roof of his mouth. He also broke his jaw.
The whole thing was devastating, to say the least. Fortunately, an oral surgeon in the emergency room was able to save 4 of his teeth and stabilize his jaw with a wire.
Come Back Tomorrow
A few weeks after his accident, Jack’s wire fell off while he was at school. I called the oral surgeon right away and she told me to go to the emergency room to have it put back on.
We arrived at the ER, checked in and waited 7 hours before we were finally called back. By this time (10:30 pm), Jack was snoozing soundly on my shoulder. After getting into a bay, we waited another hour before the on-call oral surgeon popped in. She took one look at Jack’s mouth (he never even budged) and determined that she wouldn’t be able to put the wire back on without another dentist. We were told to go home and come back to the dental clinic the next day.
So that’s what we did.
The ER Bills
Two weeks after Jack’s second visit to the ER, you know the one where nothing was done, the medical bills started pouring in. First, I got a statement from the ER. The statement had an amount for me to pay with no explanation of the charges. I called the billing department and asked for an itemized bill. Let me tell you this was no easy task. Hospitals really don’t want you to see their ridiculously overinflated prices.
When I finally got the detailed statement, I noticed that the ER visit was coded at a Level 3. Every evaluation and treatment you have in the hospital is assigned a code. These codes are used by insurance companies and Medicare to determine how much they will pay the hospital and providers for services rendered.
I knew that the Level 3 code was completely wrong. My insurance, Blue Cross Blue Shield, had paid a portion of the bill but I still owed a hefty amount. And I wasn’t about to pay it.
Levels of Care in the ER
Emergency rooms have a ‘facility charge’ based on the level of care. There are five levels of care:
- Level 1 is for minor issues, non-emergent issues like an insect bite. Or for a problem like Jack had–he needed to have a wire replaced in his mouth.
- Level 2 is for things such as an ear infection or minor cut.
- Level 3 is for moderate problems like an asthma attack
- Level 4 is for issues like abdominal pain or headache with nausea and vomiting
- Level 5 is for conditions such as blunt trauma or altered mental status
There are also coding levels for critically ill patients. If you’re curious, the American College of Emergency Physicians has guidelines for coding emergency room visits based on the extent of the assessments and treatments.
I’m sure you’ve figured it out by now. Jack’s ER visit was, by no means, a Level 3. It was, at best, a Level 1 encounter.
The Doctor Bill
Shortly after receiving the ER bill, I got a bill from an emergency room physician. Hmm, I thought, that’s curious because Jack never saw a physician.
The next day, I showed up at the hospital’s medical record department and got a copy of Jack’s chart. I was shocked to see that the physician who sent the bill had documented a head-to-toe physical exam. She commented on Jack’s mental status, his speech, his ears, his heart, his lungs, his pupils, his gait, even his pulses. Remember-no one stepped foot in his room aside from the oral surgeon and Jack was asleep the entire time we were there.
I jumped into action to start defending these fraudulent bills. Little did I know it would take over a year to get the whole thing resolved. And even then, it wasn’t a stellar solution.
The Long Fight
If I told you every detail of this story, you would likely get bored and my fingers would be tired of typing.
Long story short, I ended up contacting anyone and everyone I could at the hospital (all the way up to the CEO) to voice my complaints. I also reached out to the state attorney general, the department of health, the state medical board, my insurance company, the insurance commissioner, and consumer affairs. Over and over I was told that there was nothing anyone could do because “the physician documented what she did and we have to believe her.”
It’s worth noting that I also filed a formal complaint with Blue Cross Blue Shield’s (BCBS) fraud department. They could care less. Their response was the same as everyone else, “We have to believe what the doctor documented.” I appealed the claim based on the fact that BCBS paid the hospital way more than was warranted. And they should have paid the physician absolutely nothing. Nada.
Insurance companies turn a blind eye to fraud because they don’t want to lose big contracts with hospitals and providers. And to make up for their financial losses, they simply increase patients’ premiums. Easy peasy (for them at least).
It’s all a huge, ugly, unfair game and patients are almost always the losers.
The Half-Ass Resolution
To get me off their backs, the hospital finally waived the portion of the bill that I owed to them and to the doctor. This came after they repeatedly threatened to send my bill to collections. The ‘patient experience officer’ for the hospital had the nerve to tell me they were doing me a “big favor” by “forgiving” the debt I owed to them.
I was, and still am, furious that the hospital and provider got away with blatant fraud and abuse. And that my insurance company simply brushed it off so as not to jeopardize their lucrative contracts with the provider and hospital.
We’re All Victims
Can you imagine how many people get medical bills that contain errors and outright fraud every single day? Only a small percentage of people will actually pick up on these inaccuracies. And even those who do find errors on their medical bills may not have the time, energy and patience of steel to deal with them.
Fortunately, media outlets such as Vox, NPR and ProPublica have been analyzing and reporting on healthcare fraud and abuse, especially as it relates to medical bills. For some enlightening revelations, I urge you to dig into their reports.
What You Can Do
I hope you know you’re not alone when it comes to the frustrations of dealing with the healthcare system, Even though I’m a nurse, I still struggle to understand my medical bills and insurance claims. They are intentionally confusing and convoluted. Don’t give up! I’m here to help.
Have a question for me? Or just want to share your experiences with the healthcare system or your medical bills? Email me: email@example.com
I’d love to hear from you!