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 the 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% 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 a doctor’s 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 ER 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 emergency room 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 ER 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% 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 ER 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 OK 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 ER, 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 ER, it resulted in an ER visit charge of $1,330. But when the trauma clinic is open less than six hours a week, billing for an ER visit that doesn't tap into any of the emergency room resources feels like a scam. Is an ER 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 ER 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.
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.