Two weeks ago I wrote about my experiences with the Mendocino Coast District Hospital (MCDH) billing department after having had a colonoscopy at that institution on November 25th of last year. Here’s the background for those who might have missed the January 8th edition of the AVA (Heaven forfend!): In 2008, having reached an age at which one is supposed to undergo a colonoscopy (though there is no history of colon cancer on either side of my family tree), I did so at Mendocino Coast District Hospital. Dr. Daniel Conlin, who travels from San Francisco to Fort Bragg regularly to do several of these in a day, performed the procedure. He removed two benign polyps and advised returning for another colonoscopy in five years.
Forward to 2013 when I made sure at the beginning of the year that my Anthem Blue Cross health insurance policy was one that fully covered colonoscopies. I did so by phone with an Anthem representative and also had in hand the personalized healthcare checklist the company had printed out for me. Underneath the colon cancer screening part of the checklist were the words, “No cost to you. Covered at 100%.”
Dr. Conlin performed the colonoscopy three days before Thanksgiving, finding no polyps this time. All looked rosy until a week before Christmas when I picked up the mail at the post office and found a bill from Mendocino Coast District Hospital for $2,635.47.
As soon as I got home I called the hospital’s billing department. I spoke at length to two women who work there, the second has the title of “Director, Quality & Risk Management.” Both women claimed that the colonoscopy was billed as a surgery, not as part of a system of preventative care. The most I got from the Director of Quality & Risk Management was a grudging, “I’ll look into it.” As of the January 8, 2014 AVA story I had not heard back from her or anyone at Mendocino Coast District Hospital.
That same day, a week before Christmas, I placed a call to Anthem Blue Cross. Without prompting, the representative I spoke with noted that the November 25th colonoscopy should be fully covered, that the problem lay with either the doctor or the hospital incorrectly marking it as billable to the patient. In the January 8th article I clearly implied that the hospital made the error. Turns out it was the doctor or someone at his office, but that is the only part of this tale where our coastal hospital would prove innocent.
While I had given my phone number to MCDH’s Director of Quality & Risk Management, I never heard back from her. However, I was not sitting idly by. I continued to track the case, calling back to Anthem Blue Cross on New Year’s Eve. Getting through to a human being at Anthem while they sort out the kinks of implementing the Affordable Care Act (ACA — aka: Obamacare) ain’t easy. It usually involves being on hold for an hour or two or more. Persistence is the virtue here. I waited on hold through those hours on New Year’s Eve, January 13th and again January 16th. On New Year’s Eve the Anthem representative stated that they had left several voicemails with the MCDH billing department, but that the situation wasn’t expected to be cleared up until January 7, 2014.
I actually attempted to place calls to Anthem twice between January 7th and the 13th, but their call volume was so heavy they would not or could not accept further calls those days. I called on January 13th and waited on hold for more than two hours because that day I had received, in my PO Box, another copy of the Mendocino Coast Hospital bill for $2,635.47, this bill stating that payment was now overdue.
On the phone with Anthem on Jan. 13th, I waded through one representative who was nearly as grudging as the women at MCDH billing (in other words the Anthem rep was ready to rubber stamp the hospital’s take on things and leave me hanging with the bill). Finally, I spoke to a supervisor (presumably Anthem’s equivalent of a Quality & Risk Manager). She had the notes on the case dating back to my initial call on December 18, 2013. I waited while she read through the notes then told me about the error being in the doctor’s office, but that it had been corrected and, most importantly, I did not owe any money, Anthem was sending a check to MCDH for $2.635.47.
Much relieved, I went about my business, which on January 15th included attending a Pitchess Motion hearing in Ten Mile Court in Fort Bragg then driving over the hill to Ukiah to catch the second half of the County Mental Health Board meeting, back to Fort Bragg to drop off my laptop for some cleanup work, finally to Mendocino for the monthly meeting of the Writers of the Mendocino Coast. On the way home I stopped to get the mail, hoping for a late arrival of the New Yorker (which at times can be as tardy as the AVA is for some of the farther flung subscribers).
There was a New Yorker, but there was also a letter from the “Director, Quality & Risk Management” at Mendocino Coast District Hospital. Because it was at first glance obviously not printed in the traditional billing form I naively thought for a moment or two it might be some sort of communication detailing how MCDH had cleared things up with the doctor’s office and Anthem Blue Cross; that all was well and good here on the Mendocino Coast.
I should have suspected something was amiss when my last name was spelled two different ways within the first half dozen lines of print on the page. Below the garbled surname (and almost nothing ticks off a Highland Scot descendant more than the misspelling of their name!!) lay the following, reproduced for you here, word for word:
“Your chart and charges were reviewed concerning your outpatient colonoscopy visit on November 25, 2013 and it was determined the charges were appropriate for the procedure provided. As you may have discovered in connecting with your insurance company, a screening colonoscopy is covered 100%. A diagnostic or surveillance colonoscopy falls under insurance deductible requirements, which are impacted by a patient’s specific insurance policy.
“The physician is responsible for coding the procedure performed and determines whether it is a screening or diagnostic/surveillance colonoscopy. Dr. Conlin performed your colonoscopy and he coded your procedure as a “Personal history of colonic polyps” which would indicate a diagnostic or surveillance colonoscopy.
“I am sorry that this expense has occurred and can certainly understand your frustration. I am glad that you contacted us about this issue. I can assure you that we take your concerns seriously as this gives us a chance to review the care delivered and make sure our charges are accurate. We always want to provide quality care and make improvements as necessary.
“I recommend you follow up with your insurance carrier to provide further information regarding this issue. There will not be any adjustments on this account. You can contact _____ ________ [name withheld] in our Billing office to set up a payment plan for any amounts not covered by your insurance.
“Again, thank you for bringing your concerns to us. I hope you are doing well.”
The consternation caused by this sent me back to Anthem Blue Cross the following morning for another hour on hold, then a reassuring agent who forwarded to me an email version of the corrected billing, showing that I did not owe MCDH a penny. Why MCDH so quickly chose to send out the letter I received on Jan. 15th is beyond me.
Apparently, we’ve moved from the “audacity of hope” to the audacity of BS! One of the disturbing aspects in this whole rigmarole is that it was representatives of a huge healthcare insurance company, Anthem Blue Cross, who proved to be far, far better patient’s rights advocates than the Quality & Risk Management Director at Mendocino Coast District Hospital. The person who holds that position at MCDH and the signer of the letter quoted above is a registered nurse. The code of ethics for nurses in this country states, “The nurse's primary commitment is to the recipient of nursing and health care services — the patient — whether the recipient is an individual, a family, a group, or a community.”
That same code of ethics also says: “When the patient's wishes are in conflict with others, the nurse seeks to help resolve the conflict. Where conflict persists the nurse’s commitment remains to the identified patient.”
There is nothing on the record to suggest to me that the RN who works as the Director of Quality & Risk Management at Mendocino Coast District Hospital persisted in advocating for the patient, Malcolm Macdonald. The letter reprinted above serves to show us that the Director of Quality & Risk Management’s bottom line is billing, not patient advocacy. Placing an RN in a supervisorial role in the billing department could be beneficial to patients — if that RN was truly free to advocate for them. If in my case there was any advocacy done that I am not privy to, it clearly was superseded by a capitulation to a monetary bottom line rather than an ethical one.
If there are those higher up the food chain at MCDH who have placed an RN in the billing department then undercut that RN’s ability to advocate for patients, then SHAME on them.
Of course, the problem is the national health care system. Obamacare has taken baby steps toward getting far more people insured, and many at more affordable rates. Nevertheless, Obamacare is just replacing one expensive bandage for another. Anyone who has read Steven Brill’s in depth piece in Time magazine will remember the case of the man who bankrupted himself and other family members for an initial cancer treatment that cost him nearly $100,000 out-of-pocket in advance. His first drug transfusion cost more than $13,000. It cost the drug company approximately $300 to produce the drug. The company’s chief executive took home about $11,000,000 that year. Under the Affordable Care Act (Obamacare) that bill might very well shift from the individual to… wait for it… the taxpayers. That money is still going back to the drug company at the same $13,000 price. The drug company’s exec is still making millions and millions per year.
Brill’s study, from less than a year ago, also took a look at actual hospital bills patients were asked to pay, which (no surprise) includes incredibly inflated prices for everything, even simple items like gauze pads (around 50¢ through Amazon, $18 apiece at some “not-for-profit” hospitals). Readers who want to know more about the complex machinations of how a hospital goes about its billing business should type the term “chargemaster” into your computer’s search engine.
In case you are cursing the government because of Obamacare, think twice. The one thing that does work to curb extravagant billing is Medicare. Good old LBJ’s Medicare is helping to keep prices down. One quick example: A hospital attempted to charge over $300 for a patient’s X-ray, Medicare said no, you (the hospital) can have $24. There are hundreds of further examples, just do the research. Does anybody not know that the dreaded, cursed, socialistic concept of “Universal Health Care” or the so-called “Single Payer Plan” are nothing more than politicized terminology for Medicare for all ages? If you didn’t know, if you were lost somewhere behind a John Birch Society billboard or at your friendly neighborhood Confederate States of America Army re-enactment, let me repeat it: giving health care to all Americans would mean nothing more than expanding Medicare to include everyone in this country.
Since that doesn’t seem to be in the wind for the foreseeable future, readers must advocate for themselves when it comes to your healthcare costs. Read everything you can. Hold on to those pages from your insurance company that tell you which procedures are fully covered. Schedule your day so you can stay on hold for as long as possible. Get hold of Steven Brill’s “Bitter Pill” piece. Hold those who would overbill you at hospitals and insurance companies responsible, from the correct spelling of your name to the true cost of every last cotton swab.