The Wall Street Journal has a stellar and informative (and slightly depressing) op-ed today by Dr. Eric Michael David, recounting his recent experience taking his son to the hospital after discovering a bruise on his head. Self-pay patients who have ever had to haggle with a hospital over charges will recognize the story easily:
As a doctor and a lawyer, I like to think I’m pretty good at navigating the health-care system. So when my wife and I found a large swollen bruise on our 3-year-old son’s head more than a week after he had fallen off his scooter, I was confident we could get him a CT scan at a reasonable cost.
We live near one of the top pediatric emergency rooms in the country. The care was spectacular. My son was diagnosed with a small, 11-day-old bleed inside his head, which was healing, and insignificant…
Then the bill arrived, and you know where this is going: $20,000. Our insurance had already paid $17,000, and we owed $3,000 out-of-pocket. What for? Among the items listed on the printout was a $10,000 charge for a “trauma team activation.”
Dr. David offers some advice to patients negotiating hospital bills, based on his experience with the bill for his son’s visit to the ER. Unfortunately, and I suspect the good doctor wrote this somewhat tongue-in-cheek to make a point, most of the advice isn’t terribly helpful – most of us aren’t going to be able to follow through on #1, for example: Get yourself a job as a doctor or nurse. Other unlikely solutions include: Have the resources to pay huge bills up front while you wait the months it takes to correct billing errors (#3) and Have the combined medical and legal knowledge to understand the implications of the coders’ rules (#7).
There was one nugget in there that I thought might be exceptionally helpful to self-pay patients though. Apparently, there are online forums where hospital billing staff go to discuss how to squeeze insurance companies and self-pay patients for everything they can (I suspect that’s not the way they would characterize it). Here’s what Dr. David writes:
5. Know where the hospital billing managers go to decide what kind of upcoding they can get away with.
Most hospital billing guidelines, whether for Medicare or private insurers, are derived from a several-thousand-page manual published by the Centers for Medicare Services called the Medicare Claims Processing Manual. You can access it online at CMS.gov, although it is impenetrable. But here’s a secret: There are lots of blogs out there written by the hospital coders that do the billing, and they blog about how to ensure a hospital can make their bill stand up to the payers—i.e., insurers—whose job is to negotiate the bill down.
I went online to see if I could track down a few of these forums, and a quick Google search turned up the following:
I didn’t have much time this morning to look closely at each of the blogs, but they appear to be only moderately more penetrable than the Medicare Claims Processing Manual. I wouldn’t recommend trying to read these blogs without a good reason, but if you do have a good reason (like an unjustifiable $20,000 hospital bill) they might be worth turning to, particularly if you opt to try to handle the medical bill negotiation process yourself, instead of obtaining the services of a medical bill negotiation service (which typically charges around 20 to 30 percent of the amount saved).
Of course, the best option would be to go to a cash-friendly provider in the first place, one that doesn’t routinely charge inflated prices or bill for services that weren’t actually provided. I wouldn’t second-guess Dr. David in his decision to take his son to a pediatric ER, but for many injuries and ailments a visit to an urgent-care clinic and getting imaging at a stand-alone imaging center is probably going to be a better choice in terms of both the quality and appropriateness of care, as well as the cost.
Oh, and I highly recommend you read Dr. David’s full op-ed, I believe it’s available online to all, not just subscribers.