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The bill arrived for $1,300 dollars. Payable now in it's entirety. She had 4 other invoices for smaller amounts ranging from $50 to $300. She came to me for help.

The largest invoice was for the Emergency Care Physician, an employee of Emergency Department Physician Service who contracts with the South Broward Hospital District to staff their Emergency Departments. She paid the hospital for their part of the services when she left the Emergency Department on the date of service.

I should disclose now that I'm a certified medical coder, trained risk manager, compliance director for hire (I'm between contracts) and healthcare administrator. Anyway, I also help patients negotiate paying their medical bills for a fee on the side. I often think about writing a diary like this one, but don't. This situation changed my mind. Details below.

I looked over the bills and as an administrator I understood why all the invoices were one liner, balance forward bills. Too much detail causes the patients to call with too many questions. It's done in the hope the patient will go to the web site and pay by credit card or sit down and write a check.

This lady, however couldn't believe the $1,300 for the Emergency physician. She was incensed, "This guy put his stethoscope in exactly two places above my chest and two places on my back. He pokes me here," she showed me low on her lower right abdomen "and here!" She pointed to the her other side. "That was the total of the examination."

I asked, "What did they ask you about your history?"

"Nothing! They already had it. I've been to the hospital's out patient centers before. He asked what had happened since my last visit for my mammogram."

South Broward Hospital District has a very good regional data repository. If a doctor has privileges, they have access to the patient's information from the system. An EHR (Electronic Health Record) is a cradle to grave record of the patient from all participants. It saves a lot of time and prevents a lot of duplicated services.

I asked, "Ok. What did the doctor say was the plan for your care?"

She was a bit exasperated, "That's just it. There was no plan." My eyes goggled a bit $1,300 for no treatment plan is a bit much and was about to say so, but she continued, "Oh, there was the plan. It was admit me. Turn my care over to a specialist and let them run up the bill!" My face must have looked pretty skeptical, because the doctors I know work hard and have integrity. She went on, "I asked him what the tests showed and he told me everything showed up normal. I asked him what the diagnostics showed and he said it was normal. Every test, image, gram was normal."

I blurted out, "Then why did he want to admit you?"

"That's what I asked! He spent 20 minutes with me telling me that his only option was to admit me and turn me over to another doctor's care. I asked if he could let me go home and see the doctor Monday morning. He said no. I asked about why I needed to be in the hospital and he said so I could be monitored. I asked what for and he said to be ready if anything happened. I asked what was likely to happen since all the tests and diagnostics were negative and he sighed. I finally weaseled it out of him that if he didn't admit me, his Risk Manager would be all over him. I asked him three times about what would happen after I was admitted and he said it would be up to the doctor he transferred me to. There was no treatment plan. Just a straightforward, admit me and run up the bill."

Ahhh, I understood. "Do me a favor and write up everything you remember about that visit and I'll make us some tea."

That was almost a year ago.

She just settled the bill last week.

Here's the long of it.

She didn't need to write it out when I asked her to, she had it with her, but hadn't pulled it out yet. She had a bad feeling when she left the Emergency Department and wrote everything down when she got home that day. I'm scrubbing it of details, because of confidentiality reasons. What I immediately realized was that we needed to see more details as to how the services were coded and billed.

The South Broward Hospital District has a great PHR portal (Personal Health Record portal). We were able to download and printout a lot of information about that visit directly from my home. It was just as she said, all the tests showed a healthy woman.  We also called all the billing offices for the invoices and requested bills that specified the billing codes (the CPT & HCPCS codes) they were charging. Due to HIPAA, no one would say on the phone what the codes were, but they would mail them to the patient at the address on record.

The next step was to visit the medical record department and pay for the rest of the records. We made a date to do that. The medical records department very kindly gave her everything we needed after she showed her ID for about $10 in cash. Paying ten bucks to pare down a bill from around $2,000 to something a bit more manageable was worth it.

It only took about 2 weeks to get all the billing codes and a clear picture. Here's what I think happened. They documented they did more than they actually did and it's too easy to do with an excellent EMR software.

In a nutshell, we had one statement we used to say to providers,

If you don't document it, it didn't happen.
Because of Electronic Health Records, we have another statement that's growing in use.
Be sure to do everything that was documented, because if you don't; that's fraud.

The EMR (electronic medical record) for this woman''s emergency visit detailed a complete medical history and a comprehensive physical. They "cut and pasted" or used a copy function to transfer her medical history from a previous visit to another department and added the current history of her current problem. For the exam, they either used an automated, pre-filled "Clinical Template" or they cut and pasted (copied) from the history section. Either way, it was a problem, because the examination didn't happen as documented. There's this thing called a Review of Systems that lists all your body systems. Doctors go through the list for the history and can go through the list again during the physical examination. Physical examinations are hands on, objective observations.  

Her details of everything she remembered were enhanced with the recollections of her husband and teenage daughter who were there. They had a very good record, very detailed. What jumped out at me was the amount of time spent on trying to talk her being admitted. There was no discussion of how she could care for herself at home. That bothered me, if they thought she should be admitted and she was discharging herself against medical advice, there should have been an instruction to call 911 if her symptoms worsened.

Nobody remembered the physician examining her neck or touching it. No one saw him look into her ears, nose, eyes or mouth. She didn't say, "ah", but the HEENT (Head, ears, eyes, nose & throat) section of the medical exam was fully documented that he physically did that part of the exam. He never picked up her hand to look at her fingers and she never took off her shoes and socks, but the medical record stated the fingernails and toenails showed good color and no sign of splinters or clubbing. She never took off her shoes, socks or pants, but there was a complete genitourinary examination documented. Every body system was documented as examined, but all any of her family remembered was the stethoscope being placed in 4 spots and he poked her lower abdomen in 2 places. The physical examination was a beautiful documentation of a comprehensive multisystem examination, but it didn't happen.

That's a hellacious compliance problem, because compliance checks and protocols don't work well in identifying when your staff documents work that didn't occur. That usually requires a whistle blower.

That left the medical decision making which documented that all tests were normal, and that left the only course of action to be; admit the patient and transfer her care to a specialist, but the record didn't really specify why that was justified. There really wasn't a treatment plan.

The record ends with the notation the patient was discharged AMA (against medical advice). No after care instructions were noted in the record. There was no documentation that the patient should call 911 if her symptoms worsened.

In medical billing there are Evaluation/Management Codes the physician bills for their efforts to evaluate the patient's condition and to manage (direct) their treatment plan. The greater the efforts the higher the level of code can be selected. She was billed for the highest level of Emergency Department care. For that to be accurate, the visit had to have a comprehensive history, comprehensive physical examination and the medical decision making needed to be high (multiple treatment options and a lot of complex data to interpret). There were no extenuating factors of patient counseling. It isn't counseling if your conversation starts, ends and in the middle says, you must be admitted; but with no better justification than "because I said so".

They documented a comprehensive history, comprehensive examination and straightforward medical decision making witch limited them to billing the lowest level code, but they billed the highest level code.  

The investigation was complete.

We sent a letter to the hospital asking for a correction to the medical examination.
We sent a letter to the physician management service to look for the correction and to correct their code selection.

The negotiations were prickly.

It took at least 20 phone calls, twelve letters and 50 photocopies and some shameless use of name dropping, plus a combination of poker skills and a game of chicken, but we got those bills down to what they should've been.

First, we dealt with 2 bills that should never have been sent. The nice thing about an EMR within and EHR is that they are integrated. We had a bill for an interpretation of two tests, but the EMR didn't show the interpretation was requested. The Patient PHR portal didn't show the reports. Medical records didn't have a copy of the interpretation reports. No one had a copy of the interpretations. No one had a copy, because there were no reports. It wasn't documented, it didn't happen. We called the billing offices and both found that the interpretations were ordered, but rescinded and neither ever happened. They were both billed by mistake. That took care of $150.

This lady was uninsured last year, but due to the ACA, she rectified that problem in January. That wasn't going to help for the bill she had for services that were 5 times the Medicare rate and 4 times what United Health Care pays. We asked for a discount and pushed for more than the 10% that is often offered. We got a better discount discount and saved another $150.

We got the rest of the invoices discounted which saved her another $60.

That left the last one from the emergency physician. His management company wasn't budging. The hospital said it would take a while to investigate and correct the medical record. The management company was sure "there is no mistake". We asked for a substantial discount, no go. While the hospital was doing their investigation, the management company sent a letter and an invoice marked "final" with a threat to wreck her credit, that's when she got mad.

We sent explicit letters to the compliance directors of both the hospital system and the physician management company plus the CEO of the Hospital system that detailed the errors. We cc'd the letters showing that all the State and Federal lawmakers that have constituents that use the South Broward Hospital District. I got calls from both compliance directors and hospital's risk manager. They said they would investigate. We got a written offer from the management company to cut the bill by $400, but they wouldn't change the billing code.

We sent another letter disputing their sticking to the original billing code. We also sent a letter to the Broward State Attorney and Re'd False Claims Act (pdf) and cc'd both Compliance Directors and the hospital CEO. We were talking to the state's attorney's office about the False Claims Act and were preparing a complaint to send to them. When an invoice arrived with a discount of over $900, but it had the same billing code.

I looked at her, "It's your call, but that's a fair price, even if it's an incorrect billing code."

She sat down at her computer and paid it, printed out a receipt and a few days later got confirmation from her credit card company the transaction went through.

I shared this with a Risk Manager friend of mine. His reactions were, "No kidding? Oh, shit! OMG! and No!" He laughed at the outcome, but is unhappy at how easy it is to misuse EHR software.

I've got a few takeaways.

EHR's Make Medical Billing Fraud Easy.

This probably happens all the time.

Fraud can happen to the uninsured and the laws are the same, but there are no advocates for the uninsured.

The average patient (both insured and uninsured) has no clue when they are upcoded and overcharged.

It takes time, perseverance and more to correct medical billing and coding errors.

The U.S. health care system sucks.

We need something better.

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