Hospital bill for 25k not covered by Medicare

[6miths]

My hospital billed $140,000 for a prostatectomy. Medicare paid $32. We spoke with the billing dept of the hosp. They said they had to accept that as payment. We paid $0.

Anyone who thinks government run health care can work is in fantasyland. Lots of folks just see that the bill has been paid and they owe little or nothing without paying attention to what actually transpired. Medicare is rife with fraud, inefficiencies, and mistakes. Even when nothing goes wrong, doctors and hospitals don't receive enough to get by without the income they get from other sources.

Do you really think that the hospital got paid $32 or that it cost 'the hospital' $140k to do your prostatectomy when other healthcare systems manage to get it done just as well for less than a tenth of that. And you think that the 'private' sector isn't 'rife with fraud, inefficiencies, and mistakes' - of course much of the 'fraud' isn't fraud because it has been made 'legal' by crazy lobby driven legislation. Pass the Kool-Aid.

Oh and by the looks of the hospital lobbies, administrative offices and wards that I have been in, I would judge that they are doing very well despite the terrible drag of government 'interference' by the institution of Medicare and Medicaid.

 

[pb4uski]

Oh sure but what about the death panels we were warned about?

We've had Medicare for seniors for over 50 years and no death panels... so IMO an overblown worry.

 

[pb4uski]

Can you imagine how much longer it would take to see a doctor if everyone was on medicare? Already in California (and New Mexico I hear) you almost always see an NP, not a doctor, and that was after months of waiting. Our doctor friends in Calif tell us that they will retire if Medicare for all goes into effect. We haven't tried seeing a doctor here in Idaho yet. Don't know what that will entail.
But I do agree that the system is broken.

I don't think that it would.... you're going to have the same number of medical service providers to service the same number of patients.... except for medical service providers there would be much less complexity in getting approval for services, the amount that they woudl receive for services and how to bill and get paid for services and no or little bad debt to chase down.... so they can focus on medicine.

We're goingto have a shortage of docs no matter what.

I'm willing to take a chance given how broken the system is.

 

[pb4uski]

My hospital billed $140,000 for a prostatectomy. Medicare paid $32. We spoke with the billing dept of the hosp. They said they had to accept that as payment. We paid $0.

Anyone who thinks government run health care can work is in fantasyland. Lots of folks just see that the bill has been paid and they owe little or nothing without paying attention to what actually transpired. Medicare is rife with fraud, inefficiencies, and mistakes. Even when nothing goes wrong, doctors and hospitals don't receive enough to get by without the income they get from other sources.

Looks like it is a lot more than $32... and a lot less than $140,000.

https://www.bostonscientific.com/co...rostate-Health-Coding-Payment-Guide_FINAL.pdf

And I agree that Medicare for All reimbursement rates would need to be more than current Medicare reimbursement rates as Medicare and Medicaid reimbursement rates are so low that they are effectively subsidized by private pay patients.... but that doesn't mean that it couldn't be done.... other countries do it and pay less per capita for health care and have better outcomes.

 

[JoeWras]

Oh sure but what about the death panels we were warned about?

We already have "pain panels" in place as far as I am concerned.

Judging by some of the protocols insurance companies (not medicare) make some of us ortho patients go through, it almost seems like a study in torture.

There are a lot of protocols forced on people who knowingly can skip to the end. After hearing some stories, some of those seem to end in death (forced courses of useless antibiotics first). My dad damn near died from c-diff since they (medicare) forced a second course of a useless antibiotic on him.

So, "panels?" They are already here, government programs or not.

 

[RetMD21]

Looks like it is a lot more than $32... and a lot less than $140,000.

https://www.bostonscientific.com/co...rostate-Health-Coding-Payment-Guide_FINAL.pdf

Interesting link. I think the $7742 allowable payment for the outpatient prostatectomy is for the procedure alone. The ancillary charges would likely add substantially.

There is this claim that the Medicare payments are too low and require subsidy by other cases but I am not sure if that is true. The local hospital strongly pursues joint placements, robotic prostatectomies, and cardiac procedures the vast majority of which are done in medicare eligible patients. I know they would rather have fewer Medicaid patients showing up at the ED.

 

[SkisALot]

Actually maybe not. If it were truly universal healthcare then it might be the only game in town. This was exactly what doctors in Canada said before the transition was made. What followed was the realization by MDs of just how much better the new system was. Instead of sometimes not getting paid or being paid with barter every bill was paid in a timely fashion with no delay or complex negotiation with a third party whose main goal was to pay the lowest possible price. Doctors did not and would not quit. And many would be happy to see the massive insurance and hospital bureaucracies dramatically scaled back and paid more appropriate salaries. Much of the incredible gaming of the system which seems to happen at every level in the US would likely also dramatically decline.

There is a great peace of mind that comes with not having to worry about how you, your family and friends and your fellow man are going to obtain quality health care.

Quality?

 

[SkisALot]

Sorry about the above post with my comment in the quote section. I think I fixed it but I'm not sure.

Anyway, my comment: Because of individual variation in people - and therefore countries - all we can expect is the unexpected. If that were not true then anything good for everyone else would be good for me and that is definitely not the case.

 

[6miths]

Yes. High quality. If you think that having 12 'Emergency' Departments in a 10 square mile area (which is what the 'free' market seems to get you in many metro areas in the US) then you are sadly mistaken. Concentration of expertise and cases leads to much better care. Some of the things that happen in the US related to the seemingly infinite number of insurers and plans are truly crazy and definitely lead to reduced quality of care. The truly ironic thing in the US is that even people with the highest level of insurance or ability to pay get substandard care because 'care' itself is so profit driven.

 

[pb4uski]

In Canada, are hospitals and doctors independent entities like in the U.S. or are they run by the government (like in docs, nurses, etc are government employees)? Trying to understand how it works up there.

 

[6miths]

Well it's complicated, though not nearly as complicated as in the US of course.

Most doctors are independent, private practitioners who run their own offices and have employees. There seems to have been a large move away from this model recently in the US with MDs becoming employees of hospitals and corporations. The amount doctors charge the system for visits, procedures, etc is negotiated with the government and is published for all to see. Some doctors, typically sub-specialists in university hospitals are paid more directly by the government recognizing that since they will be seeing the most complex cases that they will not be able to see the large numbers of patients that private practitioners can. There is a concentration of services which efficiently funnels the most acute and complex cases to the appropriate level of care. There are also a relatively small number of 'hospitalists' that are paid directly by hospitals and function almost like residents did before allowable resident hours were reduced (similar to in the US).

Hospitals are not-for-profit organizations which receive most of their operating funding from government while capital improvements and equipment funding come from both private and government sources. Hospital management structures are independent of the government but salaries are paid from government funds. There is an annual 'Sunshine List' (I don't know why it is called that although I like to think that it is related to the observation by Justice Louis Brandeis that 'sunlight is the best disinfectant'). This list gives the names and jobs/locations of all 'public' employees making greater than 100K income - this includes hospital administration, some nurses and a few MDs who were paid directly. Doctors did not usually appear on the list because they were not paid salaries. Recently in my province (and for some time in some others) a list of the amounts billed by all doctors was published.

Doctors are not allowed to own laboratory and diagnostic services which are hospital affiliated or corporately owned but cannot market directly to the public. (Direct drug marketing to the public is not allowed and marketing to MDs is restricted.) There are very few 'private' for profit clinics and there has been great effort made on behalf of and resistance to further privatization.

 

[youbet]

There are very few 'private' for profit clinics and there has been great effort made on behalf of and resistance to further privatization.

6miths......

Perhaps you have knowledge of and can comment on this:

Some Canadian friends at fishing camp mentioned that some Canadians carry private, high deductible insurance policies so that in the event they want to utilize a USA based facility such as Mayo, Cleveland Clinic, Johns Hopkins, etc., they can. What's that all about? Is it common?

 

[6miths]

Not common but definitely occurs for various reasons.

Recognize that until relatively recently that Canada and the US enjoyed a much freer flow of people across their shared border and that the majority of the Canadian population is relatively close to the border. Also the population of the US is 10x that of Canada.

Relative to the population difference and that it makes sense to concentrate cases, expertise for rare diseases may be lacking or concentrated in a single Canadian centre such as Toronto - thus it could make sense to send a patient outside the country. Most commonly the centre with the necessary expertise would be in the US or could be Europe. In these instances, the provincial health plan would cover costs.

And some people do believe that some of the US centre services are better and will always want this option. Or they may be an employee of a multinational and this is a 'perk'. In my experience, this is not the opinion of anyone who actually works in healthcare in Canada and personally I don't know anyone who has such a policy. In my opinion, health care for any individual in any Canadian location is as good or better than that of a similar sized location in the US and of course everyone is entitled to receive that care without worrying about the cost.

And just as another thing to consider, health insurance in Canada (like retirement savings plans for most) is not linked to one's employer so employment mobility is improved and people are covered even between jobs which seems useful in this 'gig' economy which we now seem to have.

 

[pb4uski]

.... And just as another thing to consider, health insurance in Canada (like retirement savings plans for most) is not linked to one's employer so employment mobility is improved and people are covered even between jobs which seems useful in this 'gig' economy which we now seem to have.

IMO, the linkage with employment provided health insurance is the achilles heel of US health care.... it makes no sense. In many cases if someone changes jobs mid-year they would restart deductibles and co-pays as well... makes no sense. DS typically has a job with an employer through a temp firm and then gets hired on by the client after 3-6 months and the clients typically have health insurance.... so he is frequently jumping back and forth between subsidized ACA bronze coverage and employer coverage... it makes no sense to me at all. Your home insurance or car insurance don't change when you change jobs... why should health insurance? If an employer wants to pay a health insurance subsidy to employees to attract employees then fine.

Also, getting rid of employer provided health insurance would level the playing field in the tax treatment of the costs of health insurance.

 

[JoeWras]

.... it makes no sense.

It did when it was offered as a special fringe benefit to attract workers during the wage control era of WWII.

It has morphed into something completely different in the 75 years since.

 

[pb4uski]

It did when it was offered as a special fringe benefit to attract workers during the wage control era of WWII.

It has morphed into something completely different in the 75 years since.

Yes, I'm aware of the history.... the problem is an unintended consequence of the government restrictions 75 years ago.

 

[teejayevans]

Ignore any claims of what it costs, those are just fantasy. Insurance companies pay a fraction of those quoted rates. And so does medicare. I guess they are hoping a rich person shows up without insurance?

 

[Lstansbury]

Paste this to your WALL!

Observation status is a crock foisted on hospitals by Medicare's rules and now embraced by hospitals because they've found it a way to get more payments than they'd get for in-patient status. If it walks like a duck and talks like a duck...let's just call it a duck.

MIL was hospitalized for four days and the hospital called the first two days observation...so Medicare would not have paid the subsequent 3 weeks she spent in the nursing home afterwards. Luckily, we were able to stop the discharge because she was not stable. That resulted in two more days of "real" hospitalization and then a covered nursing home stay. (We contacted the state Medicare Quality Improvement Office and followed the protocol for disputing a discharge. That automatically stops the discharge until the review happens.)

I have nothing good to say about hospitals and their remarkable ability to give feeble, vision-impaired and drugged up elderly folks notices and waivers to sign.

Your response is so beautiful here.

I spent 8 years with Medicare Quality Improvement Organizations (QIOs) and we were are paid (a tiny few) of your tax dollars to help educate the public about things like the MOON, discharge rights, observation status, and other interesting "processes" (i.e., loopholes) that providers engage in.

It's so important that everyone knows their rights to STOP a DISCHARGE. It's the only legal process for doing this.

You call the number on the paper that every hospital is required by law to give you before you are discharged. It says "if you want to stop the discharge, if you aren't ready to go home, call this number!" And you won't be discharged for at least 24 hours or at least until your case is REVIEWED by a physician reviewer.

QIOs aren't paid much, but there are always a few brave souls working for these non-profit organizations willing to answer the phone and intervene for you, 365 days of the year, for pennies, really. Chuck Grassley and others have tried to "corporatize" these organizations - and give the contracts to their friends, truth be told (yep, I worked on the Hill to fight this). And he won to some degree, but lost the war. So, for a while, the only oversight over hospitals for Quality of Care ssues, besides a malpractice lawsuit, is a non-profit organization in every state called a Medicare QIO.

If all this sounds too much like a rant -- just remember this -- once your primary contact asks the hospital "what status is my friend being admitted under? It's not observation is it?" it's amazing how fast things change.

I've been in the meetings where leadership counted the Obs stay days in a month, chuckled over how many extra dollars they could pocket toward the bottom line. They even discussed how not to go too high in days because it might be raising a red flag. Disgusting.

It's still amazing to me that the American public isn't rioting in the streets.

 

[JoeWras]

You call the number on the paper that every hospital is required by law to give you before you are discharged. It says "if you want to stop the discharge, if you aren't ready to go home, call this number!" And you won't be discharged for at least 24 hours or at least until your case is REVIEWED by a physician reviewer.

Thanks for the info! I hope whenever I'm hospitalized, the system will have changed for the better, or I'll somehow remember this stuff.

We saw the opposite for my dad in getting him out of a SNF. He was recovering from a hip replacement and got c-diff. Anyway, after weeks in the SNF he was more than fine. Trying to get him out was like prying a buried nail out of wood. It almost seemed to me to be a case of "this guy is functional, not causing us time, but having him here pays the bills."

 

[Lstansbury]

Back to the original article. There are certain diagnoses that are ALWAYS inpatient. Surgical procedures that require extensive care afterward, regardless of length of stay, are inpatient admissions. Newborns are always inpatient admissions, as are admission for delivery. Radical prostatectomy seems to fall under this category. Medicare does not reimburse for a radical prostatectomy as an outpatient/observation status because it reimburses the procedure as an inpatient. The 48 hour rule does not apply to these procedures, but hospital administrators and billers frequently erroneously bill these as observation status, if the stay is two midnights or less, regardless of the diagnosis or procedure. They do this simply to get more money, IMO.

It's a horrible system. But the it does not appear that the patient, who was a physician, ever contacted Medicare and complain about the bill.

This document shows that-check pages 2 and 3.

https://www.bostonscientific.com/co...rostate-Health-Coding-Payment-Guide_FINAL.pdf

On page 2, this document lists the Medicare reimbursement rate for "outpatient radical prostatectomy" as N/A (not applicable) and then on the next page the document lists the reimbursement rate for inpatient radical prostatectomy. The hospital was wrong to bill as an outpatient. The patient can probably complain to Medicare. The problem is one of the rampant problems in medical billing I saw over and over again.

I got into yelling matches with colleagues over this stuff the last couple of years that I worked because doctors and hospitals only know the 48 hour rule and not diagnosis driven inpatient vs outpatient rules.

When I started practice, there was no such thing as observation status. That started in the 1990s with a major change in evaluation and management coding. First it was 23 hour observation status. Then somewhere in the last 10-15 years it changed to 48 hours for Medicare/Medicaid, and the insurance companies soon followed. Meanwhile healthcare costs go up and up, all paid for by the patient through premiums, copays, and deductibles. The insurance companies do not fight egregious charges; they just raise the rates.

But I don't understand why this doctor never complained to Medicare. They have a hotline for such issues. He might have won and got the bill reversed.

Great information here. I forgot about this -- but then the rules change from time to time. I spent a few years in a hospital contracting office coaching patients and doctors on how to intervene with their insurer to get the maximum coverage. Tips I remember:

1) always always always appeal. Very few people do the appeal and you will stand out.

Case after case was overturned on appeal, I do remember that. One lady had to appeal three times to get any of her mouth cancer surgery covered because Medicare doesn't cover "dental" and her teeth had to be removed. Jesus people, can you add any more insult to injury? It took 3 levels of appeal (the highest level), but they finally admitted they were wrong and paid $15K.

2) Contact your Congressman. They love to yell at the QIOs and the claims payers, also contracted in each area (I forget the acronym!). And their complaints do get attention.

3) The provider's business office will help you since you are willing to fight the insurance company. Keep in mind though, BE nice!! Many an ambulance ride wasn't covered because the hospital didn't submit enough paperwork to justify the need for an ambulance. You need the provider's help in this instance because they will have to go an extra mile for you.

 

[Lstansbury]

Thanks for the info! I hope whenever I'm hospitalized, the system will have changed for the better, or I'll somehow remember this stuff.

We saw the opposite for my dad in getting him out of a SNF. He was recovering from a hip replacement and got c-diff. Anyway, after weeks in the SNF he was more than fine. Trying to get him out was like prying a buried nail out of wood. It almost seemed to me to be a case of "this guy is functional, not causing us time, but having him here pays the bills."

Yes, SNF is paid by the day. Hospitals are under TEFRA limits -- the only get paid so much for a particular diagnosis code, no matter how many days you are in.

Heck, as of last time I looked, it was getting even worse, hospitals were getting "bundled" payments for hip replacements So, a hospital might get, just for example purposes, $10K for a hip, then have to pay all the other providers downstream for the next 30 days... i.e., the wound care treatment center, the home health nurse, the nursing home, etc. In these cases, you are lucky to get your Mom into a SNF because the hospital is on the hook for all expenses.

 

[JoeWras]

G
1) always always always appeal. Very few people do the appeal and you will stand out.

To whom do you appeal? Medicare? Hospital? Both?

 

[Lstansbury]

To whom do you appeal? Medicare? Hospital? Both?

Every visit triggers an MSN or Medicare Summary Notice of Coverage (which is mailed to you), that will come from the MAC -- or the contractor that pays the claims. Each region has a different MAC, it might be BCBS in one area and some other company in another. The MSN outlines what you will probably owe your provider based on what billing info the MAC has received from your provider.

On the MSN is an appeal phone number and process outlined. So you are appealing to the MAC that represents your insurer -- Medicare. (for more help with the appeal, see the SHIP info below).

FYI, Medicare Advantage plans are under many of the same laws- but not all. You should ask your plan about how you appeals are handled. It's been 2.5 years since I did this, so the regs might have changed a bit.

But calling either your QIO, or even better -- your state's SHIP program (Senior Health Insurance Program), -- will give you a leg up. the SHIP programs i've dealt with are awesome. Two or three people in your state's department of insurance office advocating all kinds of appeals for what the people we affectionately called our Medicare "bennies" or beneficiaries.

Your state's SHIP program also does a lot of stand-up education sessions for the public in hospitals, libraries, etc, depending on how their funding has been handled that year. It's usually based in your state's insurance office, even though it is all funded by the feds. - The state insurance office gets a little money (contract) to do that from the Centers for Medicare & Medicaid Services (CMS). Example, an entire state might just get $250K for the year to fund the employees, travel to do education, etc.

In my case, I was usually educating providers about the regs, their billing offices often don't know all the ins and outs. But the SHIPs, MACs and QIOS often helped each other out, i.e., and SHIP would send me bennies with weird questions and vice-versa. We also worked somewhat closely with the MACs, but as you can imagine, they were a hard hit group of people, understaffed, budgets cut, often too busy to answer the phone, even with an insider, like myself, calling them. (LOL!)

 

[JoeWras]

Lstansbury: thank you for participating here! You've provided some good info on a thread that admittedly has a lot of whining (and I'm #1 in that category). Great information!

 

[MBSC]

Medicare does not reimburse for a radical prostatectomy as an outpatient/observation status because it reimburses the procedure as an inpatient.

This document shows that-check pages 2 and 3.

https://www.bostonscientific.com/co...rostate-Health-Coding-Payment-Guide_FINAL.pdf

On page 2, this document lists the Medicare reimbursement rate for "outpatient radical prostatectomy" as N/A (not applicable) and then on the next page the document lists the reimbursement rate for inpatient radical prostatectomy. The hospital was wrong to bill as an outpatient...

Great information here...

The Boston Scientific link correctly shows CPT code 55866 under the radical prostatectomy category with a $7742 outpatient allowed amount. The code's full description is on page 1.

CPT 55866 - Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing; includes robotic assistance, when performed.

Here is the CMS update removing CPT 55866 from the inpatient-only list effective 1/1/2018:

https://www.cms.gov/Outreach-and-Ed...-MLN/MLNMattersArticles/Downloads/MM10417.pdf

I found this February 2019 article from the Hospitalist that notes that a radical prostatectomy done via laparoscopic technique was removed from the "always inpatient" list in early 2018.

https://www.the-hospitalist.org/hospitalist/article/194971/medicares-two-midnight-rule/page/0/2

+1

...diagnosis driven inpatient vs outpatient rules.

Medicare uses the CPT/HCPCS procedure codes found in Addendum E of the annual OPPS update to identify inpatient-only services. (not ICD-10 diagnosis codes)

For services and procedures that were identified as inpatient only, CMS created an “inpatient-only list” that is updated annually in the OPPS final rule.

Source: http://bulletin.facs.org/2018/05/the-2018-inpatient-only-list/

Medicare Inpatient Only List and ICD 10
I am getting several inquiries to see if we will be updating the website with ICD10 codes to check Medicare Inpatient list. The short answer is no. Medicare Inpatient list is based on CPT codes or HCPCS codes.

Reference: https://www.hospitalcasemanagement.net/en/?p=618