Is there a Catholic/Christian Physician, RN or Medical Biller on this site.. who can help me to understand?

[MarieVeronica]

Dear Catholic Answers Forum…

I am having extreme difficulty in understanding the mechanics of medical billing (and the ethics involved). I am hoping that there is a Catholic doctor, nurse or medical biller at this site.. who can help me. I appreciate your patience, as I attempt to convey the difficulty I am having with this. First, please allow me to explain our situation.

My mother is severely disabled, and requires the use of an “Afo molded plastic boot and leg brace”. When she was first diagnosed as needing this device, I was able to acquire the brace directly from a medical supplier.. at a total cost of $51.00. We paid for this.. out of pocket.

In time, the brace began to wear out. I inquired about a new brace, with her podiatrist. He seemed “horrified” that I had paid $51.00.. out of pocket for the original brace, and told me that he could order the new brace.. and that Medicare would pay the cost. At the time, I felt that this doctor was sincere, and was honestly trying to take care of us.

However.. when I received the Medicare Summary Notice.. my eye’s nearly popped out of my head. The breakdown for the new brace is as follows:

1 Afo molded to patient plastic $850.00
1 Molded inner boot $800.00
1 Plastic mod low ext pad/line $250.00
1 Soft interface below knee $150.00
1 Pre-tibial Shell molded $800.00

The grand total of this claim comes to $2,850.00. Medicare has paid $1,119.68. Which means, that we COULD be billed for $279.92. This, after the original brace cost us only $51.00. The new brace was given to us in ONE PIECE. But, from what I can tell.. Medicare was not only charged for the brace (as a single piece).. but also charged separately for the outside of the brace, the inside of the brace, the bottom of the brace and the velcro strap to attach the brace to the leg.

I have a sister who works for a Chiropractor.. and she tells me that this is a result of the biller(s) using certain “codes” when billing to Medicare.. and that the doctor himself, may not even be aware (I believe that. He’s a very nice man). She also said that the office of the doctor, will probably NOT bill us for the remaining $279.92. WELL I HOPE NOT! Given the fact that he made $1,068.68 OVER the price we paid for the first brace! Whether he’s aware of it, or not. This is pretty extreme, when you consider the fact that there are folks out there.. who can barely afford to buy a bottle of aspirin.. let alone pay for their prescription drugs and equipment.

My question is this.. is this practice morally ethical? Doesn’t this sort of thing.. hurt all of us? In a time.. when we are in such crisis in this country.. concerning healthcare for EVERYONE.. this situation certainly makes me uneasy.. and a little angry. There are probably many, many medical practices in this country.. who can honestly say “we don’t operate this way”. But if even ONE practice, is operating this way.. isn’t it hurting us all?

I ask for prayerful consideration of my questions. Please, help me to understand this. Thank you and God bless.

 

[jc-servant]

You might want to speak with someone in the doctor’s office about the billing. Just because certain charges are listed does not mean that you or anyone else will ever really pay that amount. I don’t do billing, but my job requires me to look at piles of medical records. I also have a lot of my own for the past year.

For example, I got a statement for my surgery that listed the “usual” rates for a number of things including x-rays, etc. Further down on the statement was a discount or reduction in a large lump sum. Even further down was what my insurance actually paid (the discounted amount minus my portion) because by contract, the doctor/hospital has agreed to accept a certain maximum amount in order to participate with this insurance plan.

Your Medicare statement may be something along the same lines with the “usual” amount, the discounted Medicare max and then what you will actually owe. Definitely take it into the office and have someone explain it to you. If you don’t get satisfaction, then write the doctor a letter to remind him of his conversation with you about paying less than the $51 this time around. Perhaps he will write off your portion of the bill no matter what it is since his office is giving you this pain in the neck.

 

[MarieVeronica]

You might want to speak with someone in the doctor’s office about the billing. Just because certain charges are listed does not mean that you or anyone else will ever really pay that amount. I don’t do billing, but my job requires me to look at piles of medical records. I also have a lot of my own for the past year.

For example, I got a statement for my surgery that listed the “usual” rates for a number of things including x-rays, etc. Further down on the statement was a discount or reduction in a large lump sum. Even further down was what my insurance actually paid (the discounted amount minus my portion) because by contract, the doctor/hospital has agreed to accept a certain maximum amount in order to participate with this insurance plan.

Your Medicare statement may be something along the same lines with the “usual” amount, the discounted Medicare max and then what you will actually owe. Definitely take it into the office and have someone explain it to you. If you don’t get satisfaction, then write the doctor a letter to remind him of his conversation with you about paying less than the $51 this time around. Perhaps he will write off your portion of the bill no matter what it is since his office is giving you this pain in the neck.

Thank you very much for your insights. The Medicare statement listed charges that were paid. This doctor made over $1,000.00 from the billing of this one brace (which I paid $51.00 for, the original). My sister advised me in a similar way. She said that I shouldn’t confront them with the charges… UNLESS I actually receive a bill for the $279.00. And I intend to, if I do.

But, I’m not as worried about paying the bill (though it will be a financial hardship for us) as I am about the moral ethics of this practice… and repercussions for all of us. I don’t understand why the “usual rates” are so HIGH! (And we wonder why health care plans are SO expensive? EESH! ). This is truly hurting us all! It seems to me that a small percentage of persons here… are making huge amounts of money… off the misery of people who are ill or infirmed. And I also don’t understand how any doctor of good, moral conscience (Christian, Jewish or Muslim) can accept or participate in this practice.

I am praying for the reply of a physician or two. I would like to be able to understand this. But as of now… I do not.

 

[Joe_Kelley]

I would write my Congressman or Senator and ask why Medicare paid $1,119.68 and I may be be billed for $279.92 for a brace I previously bought for $51 total.

With an election coming up, his reaction should be interesting.

 

[timotheos]

My question is this… is this practice morally ethical? Doesn’t this sort of thing… hurt all of us? In a time… when we are in such crisis in this country… concerning healthcare for EVERYONE… this situation certainly makes me uneasy… and a little angry. There are probably many, many medical practices in this country… who can honestly say “we don’t operate this way”. But if even ONE practice, is operating this way… isn’t it hurting us all?

I don’t have any knowledge of pricing in this specific area. But I can say that it is more likely to be the rule rather than the exception. In my opinion, costs in many areas are out of control, due in part to third party and government payers, pharmaceutical and medical equipment costs, and hospital costs, to name a few factors. Prices no longer reflect classic “market” values (ie. direct producer to direct consumer). You are right, healthcare is heading toward crisis mode. But any solution (eg. universal healthcare) that does not substantially hold providers and suppliers accountable for spiralling costs will only change the face of the problem, not solve it.

-Tim

 

[D317]

There are more “moving parts” involved in the insurance reimbursement/claims process than most people realize. Here are a few things to remember.

1. Medicare & Medicaid use an “allowable” for everything. For example, a doctor or hospital might spend $100 for an item but Medicare/Medicaid will only “allow” them to be reimbursed $65. That means that the doctor/hospital will only receive $65 plus a 20% co-pay (normally) from the patient. An allowable is based on many things, but one element is the “selling price” of items/procedures. The higher the “selling price” the better the chance that the provider will receive a fair reimbursement.
2. Remember, just because something “cost” $51.00 does not mean that someone else could actually “sell” it for $51.00 and make any money. Within any company, there are three major categories: direct cost (the $51 item in this case), overhead cost (the building, staff salary & beneifts, operating the office, etc), and profit (what the doctor/hospital would hope to see as the fruits of their labor). Business owners (doctors & hospitals included) must not only cover the cost of buying the $51 item, they must “mark it up” to cover overhead expenses. Additionally, if they want to make any money, they must also “mark it up” for a profit margin. This is overly simplified and there are numerous costing models, but this helps explain one element in the question. It is not uncommon to have overhead expenses at 195% to 225% or more of the direct cost. Profits vary and this is normally where any “loss” is taken. A 6% to 12% profit is not unreasonable in my opinion.
3. There is no doubt an element of gamesmanship in medical billing. Is it “right”? Hard to say without all of the facts. I’ve seen medical providers routinely get reimbursed “pennies” for very expensive items. Conversely, they sometimes (not often) are reimbursed hundreds of dollars for very low cost items. I know, its stupid, but it is also reality. This aspect of the system is very broken. Is it right to bill for services/procedures not provided? Absolutely not. Is it right to bill for everything that is provided and permitted to be billed? You tell me. No one wants to be the first person laid off because the doctor’s office can’t make payroll.

Overall, the medical system is broken. Everyone disagrees on what aspects are actually broken depending on “who gets what.”

Just one “war story”. A client in NY provided medical equipment, which included oxygen. Medicare will reimburse them for “renting” an oxygen cylinder but it will not pay for the oxygen in the cylinder. This means that a patient could come in everyday & ask for more oxygen, the provider would have to give it to the patient, and the provider would need to “eat” the cost of the oxygen. No, the reimbursement for the cylinder doesn’t cover this cost.

Now, they sold some kind of mattress (its been a long time so I’m sketchy on the specifics of the mattress) to a patient. They bought the mattress for about $1,000 and the allowable was about $6,000! go figure. Was it illegal, no. Was it ethical? You tell me.

Doing things that are illegal, untrue, and/or just plain wrong is always unethical in my mind. I would counsel a client to bill everything that is proper,actually provided, and that is within the rules they agreed to follow. I wouldn’t see that as being unethical to follow the rules.

 

[D317]

I don’t have any knowledge of pricing in this specific area. But I can say that it is more likely to be the rule rather than the exception. In my opinion, costs in many areas are out of control, due in part to third party and government payers, pharmaceutical and medical equipment costs, and hospital costs, to name a few factors. Prices no longer reflect classic “market” values (ie. direct producer to direct consumer). You are right, healthcare is heading toward crisis mode. But any solution (eg. universal healthcare) that does not substantially hold providers and suppliers accountable for spiralling costs will only change the face of the problem, not solve it.

-Tim

Tim, to your point a “classic” value equation has always stated:

[sign]Cost + Margin = Price[/sign]

Ya bought somethin (the cost), ya marked it up (the margin), and that was the Price people were expected to pay. It worked for hundreds of years and today many businesses still try to follow the formula.

There are serious flaws in the formula however. First, it assumes that the “seller” actually controls the Price and the Margin. This isn’t true for public companies just as much as it is untrue for private companies.

The marketplace controls the price it is willing to pay for goods & services (some exceptions are granted). If you go to eBay, this is very evident. There are 20 people selling the same thing & consumers can always find the “best price” they are willing to pay and the 20 sellers have nothing to say about it!

A company’s Margin is set either by shareholders (who demand it) or the ownership (who also demand it). Companies go out of business when they consistently fail to meet the profit margin requirements of shareholders/owners.

The only element that can/must be controlled is Cost. This is why I show my clients that the real value equation is:

[sign]Price - Margin = Cost[/sign]

Consumerism has created this environment where people do not recognize the “value” of any products; they only see the sales price. Remember the saying “he know the price of everything and the value of nothing.” How true today.

I see this as a bad thing. Until we start viewing the Value of items (to include medical care), things won’t get better.

One suggestion to fix the medical situation is simple. Rather than permitting the “provider” to bill insurance companies on behalf of the patient, require the patient to pay the provider and submit for reimbursement from the insurance company.

Sounds a little painful, but people would start to think about how they spend their money. Is it really worth running to the doctor at the first sign of a sniffle? The consumer can now place a value on this decision. I see this as a good thing.

Another suggestion is to **rationalize the trade-off between prevention and reactive treatment. **Medicare will not cover bathroom safety products for the elderly; but, they will cover the hip replacement when they fall in the bathroom. Today it is stupid, changing it is a good thing.

The problem isn’t “out of control costs” as you suggest. I think that my explanation shows that cost is the only thing that providers can control.

The problem is (see my previous post) how providers are reimbursed coupled with a lack of concern on the part of consumers who don’t care what they pay for anything they consume for health care. If they need open heart surgery, their $100 every two weeks in premiums better darn cover it!!

Lots of moving parts in this tough issue. God bless us all.

 

[MarieVeronica]

Finally, a few great answers! Thank you so much… everyone. I hope we can keep this one up top, for a day or so… because I think it is a very important topic for everyone.

I have to get to work now, can’t wait to get home to really dig into this. God bless.

 

[Newbie2]

I would write my Congressman or Senator and ask why Medicare paid $1,119.68 and I may be be billed for $279.92 for a brace I previously bought for $51 total.

With an election coming up, his reaction should be interesting.

Here’s what you’d get back:

Dear ____________,

Thank you very much for bringing this matter to my attention. I’ve been working my entire career to make sure that all Americans have access to quality health care. Medicare is an important part of this care for many senior citizens, and I will continue to fight on their behalf.

Blah, blah, blah.

Sincerely,

Joe Politician

…and the only thing that will be accomplished is that your time will have been wasted. :banghead:

If you enclose a campaign contribution, he or she might just sign it themselves.

 

[Joe_Kelley]

Here’s what you’d get back:

Dear ____________,

Thank you very much for bringing this matter to my attention. I’ve been working my entire career to make sure that all Americans have access to quality health care. Medicare is an important part of this care for many senior citizens, and I will continue to fight on their behalf.

Blah, blah, blah.

Sincerely,

Joe Politician

…and the only thing that will be accomplished is that your time will have been wasted. :banghead:

If you enclose a campaign contribution, he or she might just sign it themselves.

Actually I have had quite rapid response from my congressman on things like this.

For example, back when postage was $0.13 I sent a withdrawal slip to the bank. The book arrived back rather battered and a few days later I recieved an envelope with $0.15 due which contained the withdrawal slip.

I called the post office and told them they must be kidding; they wanted extra for not delivering the letter? They assured me that that was their policy. So I sent them a check for the amount and a letter explaining why I would prefer that my letters be delivered rather than returned at extra charge.

A few days later two gentlemen drove to my house from the main post office to return my $0.15. The next day I had a letter of apology from the post master at the main post office. The following day I had a letter of apology from the Post Master General in Washington.

A couple of days later I had a letter from my congressman who hoped the matter had been resolved and asking for my vote in the upcoming election - he never mentioned a contribution and I had never contributed to him.

My brother had similar quick service from his senator in Florida when my mother had a problem with Social Security.

Note that each Congressman and Senator has one or more aides whose sole function is to harass Executive agencies on behalf of his constituents.

 

[Tom_in_WNY]

I am a physician who works in the long term care setting, and am not super knowledgable about durable equipment billing, but this situation strikes me as odd.

First, the tremendous difference in price. When was the first brace bought? Is the new brace significantly different from the first one?

Second, the fact that it sounds like the podiatrist is selling you the device himself. That raises a bit of a questionable situation where the prescriber is also profiting from the sale of the durable good. In that case, the podiatrist would have a gain to be had from prescribing a more expensive item.

Finally, the fact that they say they will not be billing for the difference is actually Medicare fraud. Medicare is very keen to situations were the copay is not being billed to the patient or another third party payor. When the copay is not being billed, the system is overused.

Medicare does have a hotline for situations like this. They can explain whether this sounds right to them. The webpage is medicare.gov/FraudAbuse/HowToReport.asp.

 

[MarieVeronica]

I am a physician who works in the long term care setting, and am not super knowledgable about durable equipment billing, but this situation strikes me as odd.

First, the tremendous difference in price. When was the first brace bought? Is the new brace significantly different from the first one?

Second, the fact that it sounds like the podiatrist is selling you the device himself. That raises a bit of a questionable situation where the prescriber is also profiting from the sale of the durable good. In that case, the podiatrist would have a gain to be had from prescribing a more expensive item.

Finally, the fact that they say they will not be billing for the difference is actually Medicare fraud. Medicare is very keen to situations were the copay is not being billed to the patient or another third party payor. When the copay is not being billed, the system is overused.

Medicare does have a hotline for situations like this. They can explain whether this sounds right to them. The webpage is medicare.gov/FraudAbuse/HowToReport.asp.

Thank you for responding, Dr. The first brace was purchased less than a year ago… at a grand total of $51.00 (I got it directly from a medical supplier). There is no significant difference, from the first brace. From what I could tell… the doctor ordered the new brace from an outside source (as we had to wait several weeks, for it to “come in”). I assume he got it from a medical supplier, similar to the one I had gotten the first brace from.

This doctor has not said to me “We won’t bill you for the remainder”. That was actually suggested by my sister, who works for a chiropractor. She felt that they would not bill me for the remaining $279.00. But I have to say, even without that… I have suspected fraud already… by the outrageous difference in what I paid… and what his practice has billed Medicare for the new brace. I mean, come on… OVER $1,000.00 difference? And the way it was billed… as a whole unit, then separately for each part of the brace? Doesn’t Medicare go over these things?

If they DO bill me for the remaining $279.00… I will go into the office… and contest the charge… as it was the doctor, himself… who seemed “horrified” that I had paid $51.00 dollars out of pocket for the first brace. And the doctor (again) who encouraged me to get the new brace through Medicare… because “Medicare should pay for it”; And now, he is going to expect me to pay him $279.00?

This is what I’m talking about. Is this sort of thing morally ethical? I don’t think so. And I’m wondering… how common is this practice? It sickens me. I know people (as I said in my first post) who literally can not afford their meds… because of the cost. Makes you wonder… is this also happening when medicines are prescribed? If so, the healthcare crisis in this country is in worse shape than I thought it was. God help us all.

Thank you also for the link. I will look at it.

And thanks again, to everyone who has looked at this… and responded. If nothing else, maybe my experience is helping to raise awareness of this topic.

 

[Tom_in_WNY]

That is amazing the price differential. The folks at Medicare set the price for anything they pay for-a doctor’s visit, a hospital stay, a day in nursing home rehab, or a piece of durable equipment. If the item can be bought by a private citizen for $51, they would probably pay less. In general, Medicare is very aware of what they are paying for, and the threat of Medicare fraud is something that every provider is aware of on a regular basis. The system isn’t as broken as this example would make it seem. In fact, I have worked harder each one of the past four years, and have been paid less each successive year as Medicare decreases what they will pay me.

I believe that you can run this scenario by Medicare to make sure it is “kosher”. I can’t say whether there is any wrongdoing, but Medicare can help you.

 

[hasikelee]

I see this happen at my employer’s. Purchase something in stock, directly from us and it costs x.xx. Order it from our system, wait three weeks and it costs xxx.xx. Even if it’s the same item.

There are two scenarios for our situation:

1. It is a direct supplier to us, or we supply it ourselves, so we offer a competitive price.
2. We purchase items in bulk and get a discount.

I have also seen this with my dad’s business. He purchases inventory from a wholesaler and actually beats them out on their own prices, while still making a profit. If a customer were to purchase from his supplier, they would pay triple or quadruple.

Although the prices seem outrageous, it would be hard to say this is a fraudulent or immoral situation without knowing actual facts (e.g. how much did it really cost to manufacture? who exactly made a profit and how much and why?)

Also keep in mind that many medical items are promoted heavily when they come out, with freebies and discounts given freely.