Often at lunch I listen to personal stories from other physicians. On occasion that gives me the impetus to go off and write about it. The following is about an unsuccessful attempt by a doctor and his injured wife to navigate a small part of the healthcare system.
A doctor’s wife, let’s call her Mrs. P, fell after stumbling on some broken asphalt in their driveway. She called her husband when she realized she had injured herself and would not be able to walk back to her home or to their car. What began as a small insult to her body would end as an oversized insult to their pocketbook.
I know this doctor well enough to have lunch with him often, and I was able to follow his story from the time his wife was injured to well into her recovery. He had initially hoped to bring her to Montefiore, the hospital where we work, but because his wife was in pain and crying he took her to a closer hospital; a major medical center and one that he knew should accept his insurance.
As expected the trip was quite fast and the hospital did accept his insurance. His wife underwent the appropriate x-rays and then they both waited for the orthopedic physician to see his patient in the Emergency Room. By chance, the orthopedist on call for the Emergency Room that day also happened to be the chief of the department. So far so good.
She was first seen by an orthopedic resident in training, who took a history and examined the area, and then waited to see what the attending physician, the one with expertise to make a decision on how to treat her, would order.
She finally saw the attending physician, but according to the doctor and his wife, the attending physician didn’t really do anything more. Yes, he could see her, but he did not examine her.
The chief of orthopedic surgery, the doctor likely in charge of teaching and training of students and residents, the one whose task should be to train caring and competent physicians, never touched her, never came closer to her than a stranger might if they were to ask you directions in the street. Some type of orthopedic brace was ordered, a salesperson arrived in the ER with it, fitted her with it and she was told she could leave.
No one complained about the care and both my friend and his wife were more or less satisfied that she was feeling a bit better and had been fitted with the appropriate brace that would speed her recovery.
A few weeks later something happened that was even more painful than Mrs. P’s spill; they got the bill!
Although the Hospital accepted their insurance, the only orthopedist on call for the ER, and the person in charge of that department, did not accept their insurance. They did not discover this though, until the bill arrived. It may be possible that Mrs. P did sign something in the bunch of papers the staff gave to her when she was admitted to the ER, but they were never told by the attending physician that he was not going to accept their insurance and even if he did, they had no choice — no other orthopedist was around to treat them at that hospital. The physician that never touched his patient, the one in charge of the entire department, billed the patient for an Emergency Service Moderately Complex Visit, $1,750 dollars.
The insurance agreed to pay the doctor, who did not participate in that plan, $392.89, leaving my friend and his wife with an additional payment of $1,357.11. While a CPT code was not placed on the bill this would coincide with 99283. CPT is an acronym for Current Procedural Terminology . The American Medical Association describes CPT as “a system of terminology that is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT is also used for administrative management purposes such as claims processing and developing guidelines for medical care review.”
A 99283 CPT code, usually labeled under moderate severity, is an Emergency Room visit for the evaluation and management of a patient, which requires three key components: An expanded problem focused history; An expanded problem focused examination; and medical decision making of moderate complexity.
Did the chief of orthopedics at a major medical center just commit insurance fraud? And how many physicians are practicing and billing just like him?
But why stop at reasonable or honest, when you can easily bill for more? To continue, the doctor billed for the closure of a fracture—pretty amazing since he never laid a hand on her, and he made no mention of being a disciple of Benny Hinn or any other faith healer. He did, however, pass the mandatory collection plate in the form of an additional charge of $4,500 dollars! Say Halleluiah!
What this orthopedist did — bill the patient a very hefty service for the work his residents — is something that is likely endemic to some teaching hospitals, but clearly not allowable by the current CMS (Centers for Medicare and Medicaid Services) standards.
In general, Medicare will pay for physician services furnished in a teaching setting under the physician fee schedule only if the services are furnished:
- Personally by a teaching physician who is not a resident.
- By a resident seeing a patient in the “physical presence” of a teaching physician who documents his or her presence during the performance of the critical or key portions of the service and discussion of the case with the resident.
- Jointly by a teaching physician and a resident, seeing the patient at different times during a visit, provided the teaching physician independently performs the critical or key portions of the service and documents discussion of the case with the resident.
- When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day.
Most private insurers follow these same rules and it is quite clear to me that this physician not only set a very bad example to his students but also unlawfully billed a service he just never provided.
In the end my friend’s insurance paid an additional $1598.00 dollars, which left the doctor almost $2,000 for showing up and looking at an x-ray, and my friends with an additional bill of about $4,258.00.
What the physician, and perhaps that major medical center, which is just outside New York City, may not have known or understood or perhaps ignored, was the Surprise Bill Law passed in New York in April of 2015. A statement taken directly from that law states “Prior to providing non-emergency services, providers must disclose to the patients their rights to know what will be billed for the procedure and, if the patient requests, they must disclose the anticipated cost, warning patients that costs could go up if unanticipated complications occur.
The new law also states: “Consumers who receive emergency services will not have to pay more than the usual in-network cost sharing and/or co-payments, regardless of the network status of the providers. The emergency service providers and health insurers will have to negotiate the fees directly.”
My friend’s wife was seen by a doctor who never touched her and did not possess a tricorder ( Star Trek reference ) and yet he billed them $7,250.00 dollars! He never announced to them that while the hospital and Emergency Room participated in their insurance plan their chief of orthopedics, and the only available orthopedist at that time, did not.
Too many physicians, especially surgical specialists, are providing limited hands-on care and yet billing patients for very advanced histories and exams. Some, as I know it , use physician assistants, other students or residents to do much of their work, and some do little more than just click on formatted exams and histories, generated in the new Electronic Medical Records.
Exacerbating this unfair practice is that physicians who are taking calls at hospitals for emergencies are allowed to decline participation in the same healthcare plans that that hospital accepts. These surprise bills are extraordinary at times and unfair to the patient. New York State has smartly enacted a law the protects patients from the shocking charges and I would argue that this should be part of the Affordable Care Act and placed into effect on a national level.
About the author: Evan S. Levine, MD FACC, is Director of the Cardiovascular Center at Saint Joseph’s Hospital and a Clinical Assistant Professor of Medicine at Montefiore Medical Center – Albert Einstein College of Medicine. He is also the author of the book “What Your Doctor Won’t (or can’t) Tell You”. He lives in Connecticut with his wife and children.