On Sat, 11 Oct 2014 19:30:14 -0700, GOP_Decline_and_Fall
wrote:

On Sat, 11 Oct 2014 18:58:17 -0600, rbowman
wrote:

GOP_Decline_and_Fall wrote:

In 2012, the National Center for Policy Analysis said medical tourism
has become so profitable it’s a 100 billion market. And since both
obesity and diabetes are on the rise in the United States, more and
more Americans are asking for bariatric surgeries

Quite a few people around Ajo, AZ used to slip over to Sonoita for dental
work. There were two dentists but only one of them had an xray machine. No
problemo, if the dentist without the machine needed an xray, you'd just walk
down the street to the other guy. They both had enough work but figured they
only needed one fairly pricey piece of equipment.

In the US, every hospital seems to feel a burning need for their very own
CAT scanner and other expensive toys even if the hospital down the street
has one. You buy it, you need to make it pay for itself, so they'll fo CAT
scans for infected hangnails.

you nailed that.

Greatest healthcare system in the world...

Along with drive by doctors you haven't even seen and only become
aware of when a huge mysterious bill for out-of-network examination
appears.

U.S. | Paying Till It Hurts : Surprise Bills

http://www.nytimes.com/2014/09/21/us...cal-bills.html

Before his three-hour neck surgery for herniated disks in December,
Peter Drier, 37, signed a pile of consent forms. A bank technology
manager who had researched his insurance coverage, Mr. Drier was
prepared when the bills started arriving: $56,000 from Lenox Hill
Hospital in Manhattan, $4,300 from the anesthesiologist and even
$133,000 from his orthopedist, who he knew would accept a fraction of
that fee.

He was blindsided, though, by a bill of about $117,000 from an
“assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did
not recall meeting.

“I thought I understood the risks,” Mr. Drier, who lives in New York
City, said later. “But this was just so wrong — I had no choice and no
negotiating power.”

In operating rooms and on hospital wards across the country,
physicians and other health providers typically help one another in
patient care. But in an increasingly common practice that some medical
experts call drive-by doctoring, assistants, consultants and other
hospital employees are charging patients or their insurers hefty fees.
They may be called in when the need for them is questionable. And
patients usually do not realize they have been involved or are
charging until the bill arrives.

The practice increases revenue for physicians and other health care
workers at a time when insurers are cutting down reimbursement for
many services. The surprise charges can be especially significant
because, as in Mr. Drier’s case, they may involve out-of-network
providers who bill 20 to 40 times the usual local rates and often
collect the full amount, or a substantial portion.

“The notion is you can make end runs around price controls by
increasing the number of things you do and bill for,” said Dr. Darshak
Sanghavi, a health policy expert at the Brookings Institution until
recently. This contributes to the nation’s $2.8 trillion in annual
health costs.

Insurers, saying the surprise charges have proliferated, have filed
lawsuits challenging them. In recent years, unexpected out-of-network
charges have become the top complaint to the New York State agency
that regulates insurance companies. Multiple state health insurance
commissioners have tried to limit patients’ liability, but lobbying by
the health care industry sometimes stymies their efforts.


“This has gotten really bad, and it’s wrong,” said James J. Donelon,
the Republican insurance commissioner of Louisiana. “But when you try
to address it as a policy maker, you run into a hornet’s nest of
financial interests.”

In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had
said he would accept a negotiated fee determined through Mr. Drier’s
insurance company, which ended up being about $6,200. (Mr. Drier had
to pay $3,000 of that to meet his deductible.)

But the assistant, Dr. Harrison T. Mu, was out of network and sent
the $117,000 bill. Insurance experts say surgeons and assistants
sometimes share proceeds from operations, but Dr. Tindel’s office says
he and Dr. Mu do not. Dr. Mu’s office did not respond to requests for
comment.

The phenomenon can take many forms. In some instances, a patient may
be lying on a gurney in the emergency room or in a hospital bed,
unaware that all of the people in white coats or scrubs who turn up at
the bedside will charge for their services. At times, a fully trained
physician is called in when a resident or a nurse, who would not
charge, would have sufficed. Services that were once included in the
daily hospital rate are now often provided by contractors, and even
many emergency rooms are staffed by out-of-network physicians who bill
separately.

Patricia Kaufman’s bills after a recent back operation at a Long
Island hospital were rife with such charges, said her husband, Alan,
who spent days sorting them out. Two plastic surgeons billed more than
$250,000 to sew up the incision, a task done by a resident during
previous operations for Ms. Kaufman’s chronic neurological condition.

In the days after the operation, “a parade of doctors came by saying,
‘How are you,’ and they could be out of network or in network,” Mr.
Kaufman said. “And then you get their bills. Who called them? Who are
they?”


Doctors’ offices often pursue patients for payment. Ms. Kaufman’s
insurer paid about $10,000 to the plastic surgeons, who then sent a
bill for the remainder. The couple, of Highland Park, N.J., refused to
pay.

When insurers intervene in a particular case, they say they have
limited ability to fight back. Insurance examiners “are not in the
room on the day of surgery to see the second surgeon walk into the
room or why they were needed,” said Clare Krusing, a spokeswoman for
America’s Health Insurance Plans, an industry group. And current laws
do not require hospitals that join an insurance network to provide
in-network doctors, labs or X-rays, for example.

When out-of-network physicians perform hospital procedures, hefty
charges can be added to medical bills. Insurers often pay the full
amount or large portions, which provides an incentive for doctors to
include out-of-network colleagues.


So sometimes insurers just pay — to protect their customers, they say
— which encourages the practice. When Mr. Drier complained to his
insurer, Anthem Blue Cross Blue Shield, that he should not have to pay
the out-of-network assistant surgeon, Anthem agreed it was not his
responsibility. Instead, the company cut a check to Dr. Mu for
$116,862, the full amount.

Unexpected Fees

When Mr. Drier agreed to surgery in December, he was not in a good
position to bargain or shop around. Several weeks earlier, he had
woken up to excruciating pain in his upper back and numbness and
weakness in two fingers of his left hand, which persisted. A scan
showed that one of the disks that normally serve as cushions between
vertebrae was herniated and pushing on a nerve. With a busy job and
social life, he was living on painkillers.

The rate of spinal surgery in the United States is about twice that in
Europe and Canada, and five times that in Britain, said Dr. Richard A.
Deyo of Oregon Health and Science University, who studies
international comparisons. Studies are limited but have generally
concluded that after two years, patients who have surgery for disk
problems do no better than those treated with painkillers and physical
therapy — although the pain, which can be debilitating, resolves far
more rapidly with surgery.

The United States has more neurosurgeons per capita than almost any
other developed country, and they compete with orthopedists for spinal
surgery. At the same time, Medicare and private insurers have reduced
payments to surgeons. The average base salary for neurosurgeons
decreased to $590,000 in 2014 from $630,000 in 2010, according to
Merritt Hawkins, a physician staffing firm.

To counter that trend, some spinal surgeons have turned to consultants
— including a Long Island company called Business Dynamics RCM and a
subsidiary, the Business of Spine — that offer advice on how to
increase revenue through “innovative” coding, claim generation and
collection services.

Some strategies used by surgeons, including billing large amounts for
a second surgeon in the room or declaring an operation an emergency,
raise serious questions. The indications for immediate spinal surgery,
such as loss of bladder function or rapidly progressive paralysis, are
rare. But insurers are more likely to reimburse a hospital or surgeon
with whom they do not have a contract if a case is labeled an
emergency.

Mark Sullivan, 46, of New Jersey, went to an emergency room last year
with excruciating lower back pain and leg weakness. He was in the
operating room less than 24 hours later. “The surgeon stood at the
foot of my bed and said, ‘You need surgery; you won’t walk out of the
hospital,’ ” he recalled.

Mr. Sullivan’s emergency admission made it easier for an
out-of-network surgeon to perform the operation and bill $29,000. The
insurer paid $9,500, and Mr. Sullivan paid about $580, as required by
his plan. When the doctor’s billing office pursued Mr. Sullivan for
the balance of the bill and even threatened to turn his account over
to collection, he agreed to file an appeal with his insurer for
additional payment, but he refused to pay more himself.

A Last-Minute Surprise

Mr. Drier’s concern about extra charges began even during his
preoperative physical. The hospital sent his blood tests to an
out-of-network lab and required him to have an echocardiogram
(eventually billed for $950), even though he had no cardiac history.
(The American Society of Echocardiography discourages such testing for
patients with no known heart problems.)

His worries escalated as he lay prepped for the operating room on the
morning of his surgery. A technician from a company called
Intraoperative Monitoring Service L.L.C. asked him to sign a financial
consent form, noting that the company did not accept Blue Cross Blue
Shield plans, so he would be required to pay the bill himself. The
monitoring had been ordered by his surgeon and is considered essential
for the type of neurosurgery he was having, to make sure delicate
nerves are not damaged as they are manipulated.

“I demanded to know the price, and when he said he didn’t know, I made
him call,” Mr. Drier recalled. When the technician said it would be
$500 plus an hourly rate, Mr. Drier negotiated it down to $300.

In the operating room, he underwent a procedure called spinal fusion,
in which the surgeons removed two herniated disks that were impinging
on nerves, and inserted some bone graft as well as plates and screws
to stabilize the spine. On his hospital bill, Mr. Drier noted charges
for three implants, a total of about $10,400, as well as for two
surgical screws billed at $2,470 and $3,990 — expensive for hardware,
he thought, but his insurer paid the full amount.

The biggest surprise was the bill from Dr. Mu, the assistant surgeon.
Fusions generally require a second trained pair of hands, but those
can be provided by a resident or a neurosurgical nurse or physician
assistant employed by the hospital, for whom there is no additional
charge. The operative record for Mr. Drier’s surgery states that no
qualified resident was available.

Dr. Mu is the chief of neurosurgery at Jamaica Hospital Medical Center
in Queens, though he sometimes operates at other hospitals. According
to a database that tracks hospital admissions in New York State, most
operations he performs at Jamaica involve emergency surgery on
Medicaid patients, often victims of trauma — a challenging but
probably not very lucrative practice.

One insurer, Aetna, is in court with Dr. Mu’s private-practice group,
NeuroAxis Neurosurgical Associates of Kew Gardens, Queens. NeuroAxis
sued to recover higher payments for its out-of-network assistant
surgeons; Aetna says the practice’s fees for those surgeons are
excessive. J. Edward Neugebauer, chief litigation officer at Aetna,
said the company had also sued an in-network neurosurgeon on Long
Island who always called in an out-of-network partner to assist,
resulting in huge charges. The surgeons shared a business address.

Surgeons from other specialties also team up: After Gunther Steinberg
of Portola Valley, Calif., had a needle biopsy of an eye lesion in
2010, he discovered that his insurer had paid about $10,000 to the eye
surgeon who performed the outpatient procedure and $10,700 to a second
ophthalmologist in the room.

“The idea of having an assistant in the O.R. has become an opportunity
to make up for surgical fees that have been slashed,” said Dr. Abeel
A. Mangi, a professor of cardiac surgery at Yale, who said the
practice had become commonplace. “There’s now a whole cadre of people
out there who do not have meaningful appointments as attending
surgeons, so they do assistant work.”

In Mr. Drier’s case, each surgeon billed for each step of the
procedure. Dr. Tindel billed $74,000 for removing two disks and an
additional $50,000 for placing the hardware that stabilized Mr.
Drier’s spine. Dr. Mu billed $67,000 and $50,000 for those tasks.

If the surgery had been for a Medicare patient, the assistant would
have been permitted to bill only 16 percent of the primary surgeon’s
fee. With current Medicare rates, that would have been about $800,
less than 1 percent of what Dr. Mu was paid.

Visitors Who Bill

Unexpected fees are routinely generated outside the operating room as
well. On the wards, a dermatologist may be called in to examine a rash
and perform an expensive biopsy. The person in scrubs who walks a
patient to a bathroom for the first time after hip surgery may turn
out to be a physical therapist billing $400.

Mr. Sullivan, who had the emergency back surgery, discovered charges
from more than 10 providers in the 48 hours after his operation. (The
surgery involved simply trimming a herniated disk in his lower back.)
He wrote to various doctors to dispute bills, saying, “I was admitted
to Overlook Hospital from Nov. 26-27, 2013, and I have received
numerous invoices for procedures that were never done, by physicians
that never treated me.”

He was puzzled by $679 in occupational therapy charges involving the
delivery of a device to help him put on his socks, which he never
used. He was irate about charges from a group of hospital-based
primary care physicians from Inpatient Medical Associates, who visited
him briefly once a day and billed close to $1,000 in out-of-network
costs.

Healthy surgical patients typically do not need a general doctor; an
anesthesiologist clears them for surgery. Mr. Sullivan noted that if
he had needed an internist, he would have called his own, who is in
his insurance network and whose office is just down the block.

Dr. Mangi, the Yale cardiac surgeon, said hospitals often encouraged
extra visits for both billing and legal reasons. He said he was
required to request a physical therapy consult before each discharge,
for example, even if he felt there was no need.

“You can cut fees, but institutions find ways” to make the money back,
he said. “There’s been a mushrooming industry of mandatory consultants
for services that neither doctors nor patients want.”

A Possible Remedy

For months, Mr. Drier stewed over what to do with the $117,000 check
Anthem Blue Cross had sent him to pass on to Dr. Mu, refusing to sign
over a payment he considered “outrageous and immoral.” He worried that
such payments could drive up premiums at his employer.

In the past few years, some insurers have filed lawsuits and sought
injunctions to prevent providers from going after their clients for
payment of unexpected medical bills. Dr. Scott Breidbart, chief
medical officer at Empire Blue Cross Blue Shield, part of the same
parent company that covers Mr. Drier, said that it had not taken that
route, but that in some situations it had refused to do further
business with in-network surgeons who repeatedly called in
out-of-network assistants.

A New York State law that will take effect in March — one of a few
nationally — will offer some protection against many surprise charges
and require more advance disclosure from doctors and hospitals on
whether their services are covered by insurance. It states, for
example, that patients are not responsible for unforeseen
out-of-network charges beyond what they would have paid in-network. It
directs insurers and hospitals to negotiate any further payment or
enter mediation.

In many other countries, such as Australia — where, as in the United
States, people often rely on private insurance — it is seen as a
patient’s right to be informed of out-of-pocket costs before
hospitalization, said Mark Hall, a law professor at Wake Forest
University.

“I couldn’t beat the medical billing administrators that knew how to
say the right things and never said anything wrong and knew the laws
backwards.”

Mr. Drier tried to negotiate with the surgeons to divvy up the
$117,000 payment in a way he believed was more fair; he liked Dr.
Tindel and felt he was being underpaid. Mr. Drier’s idea, he wrote in
an email, was to settle on “a reasonable fee for both the surgeon and
assistant and return the rest of the check to the insurance
company/employees” of his company.

But in July, he received a threatening letter from Dr. Mu’s lawyer
noting that he had failed to forward the $117,000 check. So he sent it
along, with regret.


Have you experienced surprise medical charges that you learned of only
when you received a bill or an insurance statement? Please share your
story.


Trevor S Los angeles, United States Insured

This happened to me several years ago.. To this day the whole
situation infuriates me. I voluntary went to the emergency room to get
6 stitches from a biking incident. They called an orthopedic
specialist in. He was out of network and the final bill was 15k. My
insurance covered the first $2,500. After 9 months of negotiations, I
settled for $2,500 on the $12,500 remaining. I didn't know he was out
of network and had no idea that the bill would be so high. This is a
common loophole and needs to be addressed urgenty.
Concerned Health Consumer NY, United States Insured

I went to an ER on a Sunday afternoon not knowing that it was a
huge mistake! I did not realize that my non-life threatening red rash
(which turned out to be an insect bite would cost me close to $1000
-$700+ for room' $300 for the PA. I was not confined in the ER -- the
room was used for consultation and blood test. I was shocked by the
cost of the PA. The billing group explained that the cost is based on
service, not the person who sees you.
Nina L Glen Burnie, United States Insured

I was recently hospitalized at Johns Hopkins Bayview Medical Ctr.
While recuperating in the recovery room, I was visited by a Diabetes
Team. I was drugged and in pain and have no idea why the team felt the
need to visit me in recovery but never visited in the days that I was
hospitalized if this condition or issue was so important. I have
disputed the charges as I feel that I was not rendered a service and
felt that I was billed because I have insurance. By the way, I am not
diabetic.
Kevin Pietila Vancouver, WA, United States Insured

After having chest pains and going to Urgency Care at PeaceHealth,
the medical staff their couldn't find anything wrong with me, but
suggested that I go to the Emergency Room to be sure. Upon arriving, I
was treated to an EKG and a blood test and released an hour later
after finding no apparent problems. I was then charged over $5000 plus
my Urgency Room visit. Insane. Even your mechanic or veterinarian
consults for their services and gives you options before they charge
you.
Jane Q Minneapolis, United States Insured

My brother was hit by a car running a red light while he was
walking across the street. He was out training for a marathon. His
neurosurgeon did not file the claim with the insurance even though my
sister-in-law called them to file it/post-certify it. He is now trying
to have my brother pay for it. It seems like he assumed my brother
would be getting a large settlement from a lawsuit which never
happened since he was hit by a guy who had minimal insurance. The
neurosurgeon now has a lien on any settlements he gets. Email

Dennis P Boca Raton, United States Insured

After my wife's screening colonoscopy by a network provider, in a
network outpatient facility, with a network anesthesiologist, we
received a 2300 bill from a pathologist-who is a member of the
gastroenterology group. He is a ctually a participating provider but
heres the rub... and they know this quite well---all pathology is
supposed to go through the contracted pathology group. This
pathologist doesn't have a contract with the insurance company for
doing work. The insurance company is running interference, and say we
owe nothing here-but we have gotten 2 bills from the Gastroent group.
George D Arlington, VA, United States

Yes. This story resonates. My wife recently received a bill from
an out-of-network lab based in New Jersey which her primary physician
(Blue Cross/Blue Shield network) in Virginia used for one of her
routine tests. I find it hard to believe that they could not have
found another lab within the BC/BS network. The test was standard
issue, nothing exotic.
Bob K Flushing, United States Insured

I am outraged by what I have read-not only in your story but the
patient replies. I am an in-network doctor and past president of my
county medical society. Today, my office received three calls from
patients scheduled for surgery, who are fearful of out of network
charges. I receive a pittance in network and yet others are billing
unconscionably. The insurers could stop this in a second by denying
coverage. Instead, there is no $ left for honest doctors. The extent
of this scam is beyond my wildest nightmares.
Sue Hunt Houston, Texas, United States

Yes, I had a colonoscopy and I received bills for doctors I never
saw, who never provided any services to me and were all
out-of-network. I told them I would not pay any out-of-network doctors
unless I agreed before the procedure. They insurance company agreed
and told them no, they would not pay and I was under no obligation to
pay since I did not agree to their services. It is a scam like a
con-artist. They are just trying to bilk the public out of money when
it is denied by the insurance company.
Bonnie Garfield York, United States Insured

I recently had a lumbar fusion. All the charges were covered by by
insurance plan, except one, a monitoring service. I asked my PPO to
cover their part, and they did. The service has not yet re-billed me.
About 3K. I basically said that I was under anesthesia and unable to
screen everyone in the room, how can I check to see if someone is in
my PPO or not? Very angry about this. I've reached my out of pocket
and now this on top of everything!
This kind of CRAP, fortunately, does NOT happen under the Canadian
system.

On Sat, 11 Oct 2014 23:04:04 -0400, wrote:

The rate of spinal surgery in the United States is about twice that in
Europe and Canada, and five times that in Britain, said Dr. Richard A.
Deyo of Oregon Health and Science University, who studies
international comparisons. Studies are limited but have generally
concluded that after two years, patients who have surgery for disk
problems do no better than those treated with painkillers and physical
therapy — although the pain, which can be debilitating, resolves far
more rapidly with surgery.

Ill have to say that back surgery WORKED for me. Nicely.

Then I went back to doing the same stupid **** that hurt me the first
time..and had to have a second surgery 12 yrs later. Its now been 25
yrs since my last one..no issues noted.

Gunner

"At the core of liberalism is the spoiled child,
miserable, as all spoiled children are, unsatisfied,
demanding, ill-disciplined, despotic and useless.
Liberalism is a philosophy of sniveling brats."
PJ O'Rourke