3. Upcoded: You’re Never Done Paying
This week, we’re talking about upcoding, and how it can lead to $11,000 COVID tests, $629 bandaids, and mothers waiting within sprinting distance to the hospital. America has some of the best doctors and hospitals in the world, but many patients are too afraid to walk through the doors for fear of going into unnecessary debt.
Keep up with David on twitter @CHIDavidSmith.
Resources from the episode:
- Share your coronavirus medical bills with Sarah Kliff & the New York Times: https://www.nytimes.com/2020/08/03/reader-center/coronavirus-medical-bills.html?smid=rd
- Learn more about the $629 band-aid on The Impact, a podcast created and formerly hosted by Sarah: https://podcasts.apple.com/us/podcast/the-curious-case-of-the-%24629-band-aid/id1294325824?i=1000393574994
- Read Marshall’s article about Dr. Zachary Sussman’s $10,984 COVID test: https://www.propublica.org/article/how-a-covid-19-test-led-to-charges
- Pre-order Marshall’s book, Never Pay The First Bill: https://www.marshallallen.com/
- Check out Marshall’s Top Doctor award: https://www.instagram.com/lemonadamedia/
- Become a better health care consumer with the help of ProPublica’s voices of patient harm: https://www.propublica.org/article/patient-safety-voices-questionnaire-results and Sarah’s reporting for Vox: https://www.vox.com/2019/3/22/18261698/how-to-fight-expensive-medical-bill
Learn more about your surgeon before an operation with ProPublica’s Surgeon Scorecard: https://projects.propublica.org/surgeons/
Keep up with David on twitter @CHIDavidSmith.
Have you been hit with a surprise bill or had an infuriating run-in with the health care system? If you want to submit a patient story, email us at email@example.com or leave us a voicemail at 833-453-6662.
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Zach Sussman, Sarah Kliff, Marshall Allen & David Smith
My name is Ariela, I have four children and a husband and we live in Los Angeles. A few years ago, I had to have physical therapy. And I also wanted to know the price. The physical therapists office said, call the insurance company, the insurance company told me to call the physical therapy office, and it just went back and forth. And it was at that time that I knew that this is the way it was going to be, and that I was never going to be able to know how much anything costs. And so anytime we needed any kind of medical service, it was really like prayer that we could just afford it. I actually have two instances recently where I have canceled tests that my family needs, because there’s just no way to know how much it’s gonna cost. And I just can’t do it anymore. It’s just too expensive.
We pay a lot of money every month for our private insurance. But even so, we will get hit with these huge bills. At this point, it’s pretty much catastrophic insurance. So we keep it just in case something really horrible happens. But by the time you’ve finished paying the premiums, and by the time you’ve finished paying off your deductible, you’re like, $25,000, $26,000, $27,000 in, and then you still have to pay when you go to the doctor, and you still have to pay for your medicine. It’s not like you’re done paying, you’re not done paying, you’re gonna pay and pay and pay.
Ariela’s story is far from unique. Since we launched the show a week ago, we’ve heard from listeners all over the country who have emailed and called in to share their personal stories. And so many of you have found yourself in a position where a simple trip to the doctor turns into 1000s of dollars in fees. Some of you are left battling it out with your insurance companies. Others of you were trying to pay it all out of pocket, but everyone feels left in the dark. Why is it impossible to predict what anything is going to cost ahead of time? And when the hell did a trip to the doctor become a financial game of Russian Roulette? How can anyone justify the state of the current system?
David Smith 02:32
This is the COST OF CARE. I’m your host, David Smith.
Today, we’re talking about medical billing. And to start, I sat down with Sarah Kliff. She’s a reporter at the New York Times and like me, she actually enjoys talking about the stuff in healthcare that most people find kind of boring.
I love policy, I find it super interesting. You know, I find risk adjustment and all those little wonky things that actually is, you know, David, matter a lot. And the reason I think I find it so interesting is not, you know, I like reading long wonky documents, probably more than the average person but I really find it interesting because all this policy affects people.
Sarah said that even though she focuses on patient bills, some of the most damning stories are the ones that don’t have paper trails. Like one mother, who contacted her recently to share what happened when her 2-year-old daughter got into her purse and took a bunch of Dramamine tablets.
2-year old’s are very, you know, interested in putting anything they can in their mouth. And she wasn’t sure how many Dramamine pills were in there getting with or how many her daughter ate. So she calls Poison Control and Poison Control says, you know, she’s probably fine, but we think you should take her to the emergency room because there is a risk of seizure. If she does have a Dramamine overdose. This mom turns out to have already $1,200 in medical debt from an emergency room visit a few months prior. And the mom is thinking like I haven’t even been able to pay that bill. Like I don’t have the money to go to the emergency room. I don’t know how much it’s going to cost. I know it’s gonna be expensive.
Sarah Kliff 04:21
So what she does is, you know, her and her husband, they get in the car, and they decide they’re going to sit in the parking lot outside the emergency room. And if their daughter starts having a seizure, they’re going to run in and get her treated. But if not, they’re just going to sit there and monitor her kind of, you know, within, you know, sprinting distance to the emergency room door. So their daughter watches the Little Mermaid. They sit there for a few hours; nothing happens and she goes home. And I think it just speaks to like the way Americans interact with the healthcare system, where you have cases where parents are being told you should bring your child to the healthcare system for monitoring and patients are just too scared of the billing implications.
And this mom said she felt terrible, you know, she felt incredibly guilty. She felt like a bad parent. But she also had to think about the real-world financial consequences. And it’s not crazy to you know, think that if she had taken her daughter, and you know, that might have been another $1,200 bill. So I think you know, what’s really wrong is Americans just can’t have any sort of reasonable sense of what sort of financial consequences they’ll face for interacting with our healthcare system. It’s really unpredictable. And so you have situations where that are really hard to document. Do you know, that’s not going to show up in a medical bill this mom’s decision, but when I wrote about her story, I heard from many other parents who had made the exact same decision who decided not to take their kids to the emergency room, even though they were told to because they were worried about the financial implications.
When Sarah shared this story, it hit me like a ton of bricks. First off, I’ve been the 2-year-old in this scenario. When we were kids, my brother and I drink a full bottle of cold medicine, and my terrified mother decided to call the Mormon missionaries, rather than take us to the local emergency room. Long story short, we eventually threw up and everything turned out to be fine. But the clinically appropriate thing to do was probably to get us to the ER. But like Sarah said, a lot of parents are forced to make these kinds of decisions because they’re afraid of going into unnecessary debt. In economics, we call this a classic trade off. This is how a consumer decides if it’s worth making a sacrifice in order to get a certain product or service.
David Smith 06:40
Like, oh, if I spent my money on pizza today, I won’t be able to go to the movies tomorrow. Only in America, we apply this trade off logic to our health. Can you imagine anybody that has ever had a child, a two-year-old child, the prospect of sitting in a parking lot watching that sweet, innocent thing, watch Little Mermaid, while you are monitoring for any physical sign of distress to determine whether or not it is worth going in and paying the $1,000 to $2,000 towards your deductible for that child’s care, that’s a *** way to make a trade off. No parent, no child should ever be subjected to that. And why is that inappropriate? Because what tradeoffs, what consumer tradeoffs don’t value in our healthcare system is what’s clinically appropriate or not, there was a clinical basis for that little girl to be seen by a doctor immediately. And no parent should ever be in that position. Sarah Kliff hears about these kinds of bad tradeoffs all the time in her reporting. She became fascinated by medical billing a few years ago.
I got this bill from a patient. And he was a new parent, he had been clipping his daughter’s fingernails, he clipped too close to the edge and blood starts spreading out. And he’s like freaked out, he doesn’t know what to do, to weekend, the only place that’s really open that can see his daughter is an emergency room. So he takes her there. Turns out she’s fine. You know, they put a paper towel on it and a band aid, the band aid pulls off in the car ride home, everything’s totally fine. And her finger, you know, is no worse for the wear. And he thinks that’s the end of it until he gets this $629 bill for this encounter he had in the emergency room.
Sarah Kliff 08:32
And he sent it to me, you know, asking, how could a band aid possibly cost $629? And I said, You know, I don’t know the answer to that. But I’m a curious person. And it’s kind of my job to find out. So I’m going to find out. And that, you know, I didn’t know that at that time. But that kind of set me on this path of really using patient bills as a way to understand the American healthcare system.
I mean, I have to block out the part about a parent clipping a child’s fingernail too close to the edge, because every time I do this for my 8, 6 year or 3-year-old, they’re convinced that’s going to be the outcome, which makes me convinced there’s a risk
I’ve ever since I wrote that I didn’t have a kid when I wrote that. But I do now and my husband’s in charge of all nail clipping duties because I’ve decided I’m just too terrified on it.
Yeah, no, it’s weirdly one of the most terrifying things as a parent. So glad to know I’m in good company. It’s the first time I’ve ever said that out loud. Okay, so you ask people to share their bills. You’ve shared a lot of these things, obviously, over the years through your own Twitter feed. Tell me what as you’ve looked at these, you’ve reported on this. What are the different patterns you see in these medical bills?
Yeah, I think a few big takeaway so I’ve run two projects where I’ve collected a lot of medical bills one was at Vox collecting emergency room bills. And then there’s one I’m running at the New York Times right now where we’re collecting bills for Coronavirus testing and treatment. And across the two of those, there’s a few things that jumped out at me. One is just how little information patients are able to obtain or go into these health care encounters with. It’s just really hard. You know, when you set foot in emergency room when you go to a Coronavirus testing site to know how exactly you’re going to be billed. There’s no sign somewhere usually telling you, you know, this is how much it costs. You know, these are emergency rooms, the things I learned in my last project is emergency rooms, typically charged some kind of facility fee, almost like a cover charge just for coming in and using that service. And those facility fees, you know, are not posted on the door somewhere you find out when you get your bill.
David Smith 10:41
This is why we have parents parked within sprinting distance of the hospital waiting for their toddler to have a seizure. Patients are conditioned to fear these big bills but have no way to research ahead of time just how big they’ll be and other industries, the government’s actually stepped in to try to level the playing field. Take cars, for example. Back in the old days, dealerships didn’t have to disclose the history of the used cars. So you had no way of knowing if that perfect looking car had just been on Iraq. That’s something called information asymmetry. And the government decided that wasn’t good for consumers and said, sellers, you’re required to tell the buyer what they’re buying. But we treat doctors very differently than used car salesmen.
Yeah, the problem is, we trust our doctors and hospitals, we’re out of our area of expertise. And so when they tell us we need something, we trust them, and so we do it. But the reality is, often we don’t need that thing, or there might be a less expensive version of that same service that we could get.
That’s Marshall Allen. He’s a reporter with ProPublica and author of the forthcoming book, Never Pay The First Bill. And like Sarah, Marshall has been covering medical billing for a while. You’ve been doing this for 15 years, and you’ve had a unique lens on the patient, which means you’ve probably just seen some crazy, crazy *** for over a long period of time. You wrote an article through ProPublica back in November of 2017. The headline is a hospital charged $1,877 to pierce a five-year old’s ears, $1,800 for an earpiece, like how did that happen?
Marshall Allen 12:35
Well, so that story was part of a series I did that year on wasted healthcare spending. And studies show that we waste between say 25% to 33%, about a third of all healthcare spending might be wasted. And it’s wasted on things like high administrative costs, unnecessary care, high prices, you know, administration. And that’s again, one of the things that is most outrageous to me, is that when they do something wrong, or something unjustified, they don’t back down. In fact, they often double down. They don’t treat people with fairness, even when they’ve done something ridiculous, like charge $18,000 for an ear piercing.
A lot of the absurdity stems from the fact that most of our health care system is based on something called a fee for service model.
Fee for service payment means that each time that doctor or hospital perform a service, they get paid a set amount of money. So that would incentivize people to do more services, because that’s how they make their money. So for surgeons, they only get paid under fee for service if they perform an operation. And so if you’re a surgeon who’s an independent surgeon working with a hospital, you make your money by doing procedures. And so then your incentive when a patient comes to see you is to put them under the knife. And so the fee for service model of medicine has led to a lot of overtreatment, because people get paid more when they do more. If I was paid by the word for the book I wrote, I might write a million words. If you’re going to pay us more for what we do, well, we’re going to do more of that thing. But nobody needs. Nobody needs a book like that. It’s kind of a silly example. But I think the point is, we all have that same temptation.
David Smith 14:31
So hospitals have this natural incentive to offer as many services as possible. And patients have no idea if they even need those services or how much any of it costs.
One of the things I saw when I was looking at emergency room bells is a lot of women get pregnancy tests. If you go to the emergency room, they’re often going to do a pregnancy test because you know, they want to make sure not pregnant before doing whatever treatment and the price can just vary from, you know, maybe $20 like I saw one, two up to $400, and you don’t know if you’re going to the emergency room that charges $20 for a pregnancy test or $400. The person giving you the pregnancy test probably doesn’t know the answer to that question, either. But the variability is it’s just giant. It’s all over the place. And you know, this isn’t just in my work. We see this in a lot of data about the health care system that is simple blood tests can vary by a hundredfold depending on who is doing it.
After the break, we shift from pregnancy tests to COVID tests and learn that even doctors are not immune to wild medical bills.
Hey, listeners, we want to hear your stories. Have you been hit with a surprise bill after a procedure? Did you have a run in with the health care system that felt infuriating or unfair? Or have you struggled to find in-network providers in your area? Share your story now by calling 8334-LEMONADA. That’s 833-453-6662 or email us at firstname.lastname@example.org.
David Smith 16:16
Welcome back. After our interview with Marshall, he introduced us to a guy named Dr. Zachary Sussman. He’s one of the stories featured in Marshall’s Book. Early in the pandemic. Dr. Sussman was working with Physicians Premier, a freestanding emergency room in Austin, Texas. A big part of the job was overseeing Coronavirus testing. So when he found himself feeling a bit under the weather, he decided to get tested.
I had maybe we had a slight headache or feeling a little off. And I think everybody at that point is if they felt an itch was worried they had Coronavirus, so I’m like, alright, well, you know, I’m in a position here where I can just mosey into my own clinic and you know, they’ll stick me and they’ll read it out. And, you know, it’ll be on the house. And, you know, I’ll check in on things and just..
You’ll get the antibody, get the COVID antibody employee discount.
Exactly, exactly. I kind of had to tell them who I was. But I certainly declared myself to be one of their contracted physicians. The receptionist told me that I would not receive a bill but they politely requested my insurance card, which I forked over, I was shown to a room, my vitals were taken, blood was drawn. I was just talking it up with the nurse about why I was there and what I was doing with the company and the ER doc came in and we had a pleasant conversation about how testing was going in the organization and the ER doc did a cursory interview with me about you know, any symptoms I was feeling. The medical part of the interview, I would say lasted less than three minutes. And then it just turned into professional banter.
David Smith 18:00
He left the appointment, got his results negative, and he figured that was the end of it until a few weeks later when the explanation of benefits arrived in the mail. Okay, so let’s talk about the bill. You’re coming home on one sunny Austin afternoon and you’ve had a great day and you get to your mailbox.
Not working at the time because of Corona. Quarantine life. Yeah, taking two-hour walks around my neighborhood. The first one I believe was for I think around $2,300
So you’re probably thinking to yourself $2,300, okay, I know healthcare is super expensive. And yeah, this guy only spent three minutes with me, but you know what, my insurance company’s paying for it. I don’t really have a grievance. $2300 that stinks for somebody, but I’m gonna move on.
Yeah, that is exactly what I thought, I sort of just said, like, I got myself into this. I knew it was expensive. I had a nice bottle of water in the lobby, the Lexus VR experiences, I wrote it off essentially as okay, this is expensive, but I guess it’s within the realm of expectations for this type of facility.
It was pricey, but it didn’t raise any major red flags, until he got another notice from his insurance company.
So another EOB arrives. This one is for I believe, $12,800. So you know, add it on to the other one, it’s, you’re looking at a $13,000 check here for 10 minutes of interactions.
So how did we get here? How did the supposedly free antibody tests end up costing the insurance company $13,000? Well, we have a little thing called Upcoding to thank for that. Upcoding is the result of a process that begins in the doctor’s office, you go into the doctor’s office, and that interaction is all captured by the doctor, you’ll think of the doctor and the nurses sitting behind the terminal typing and things not making eye contact with you while you’re talking and recording every element of the visit. And you go out the door and you check out and they say, okay, your copay is $25. And you think to yourself, fabulous, that was a good deal. And then what happens in the backroom is sometime later that day, somebody is going to pull up the nature of that interaction, and they’re going to say, alright, what do I get paid for out of this interaction.
David Smith 20:39
And so there’s a very sophisticated software that allows for doing this. And what will happen in the back room is, you’ve got to extract every ounce of value out of that visit you can so the $25 visit you thought you just had has now turned into a $2,300 interaction that has now been sent to the insurance company and the insurance company looks at this and says, consumer, you have a $10,000 deductible so you owe us the $2300 minus the $25, the patient gets the bill and says oh my god, I thought that was $25, how much? And they’ve got to write a check for it. On the other hand, the insurance might just cover it all, and you don’t have a deductible or anything else you have to pay for. But either way, the upcoding process is working outside the view of the consumer to make as much money as possible.
They are trained to translate the medical record into a claim. And they are certainly trained to maximize the claim as much as they can. And this is where you see huge problems with Upcoding. Across the board. This is one of the biggest problems I think that we have in our rising healthcare costs is upcoding. So, for example, another patient I talked to cut her finger, while she was slicing an avocado, she got three stitches on her finger, they build that as a level three emergency room visit, a medical three emergency room visit requires some degree of medical complexity and decision making and a full examination.
Marshall Allen 22:18
I mean, you can’t just assign a level three for something that this would have been more like a level one really, I mean, this was as simple as it gets, she just needed three stitches. Well, they build it as a level three, you get paid way more money for level three than you do a level one. And so if it’s more medically complex patient, they can maximize their revenue when they submit that to the insurance plan.
Now, you would think that insurance companies would be on the front line fighting against upcoding, right? I mean, they’re all about the bottom line. But it turns out, not so much. When Dr. Sussman insurance company, Golden Rule got the $11,000 claim for his visit, they paid it in full, no questions asked. And this is where most people would just walk away. The price was insane. But it’s not like he got hit with a bell. But Dr. Sussman isn’t like most people, this felt really wrong. So he kept pushing.
What motivated you to make the phone call to Golden Rule, like I’m thinking about how I would have acted in this scenario, I would have seen it, I would have thought this is a little ***. And then I want to see what the insurance company paid it out, I would have flagged it and I would have been a little indignant, but I probably would have gotten on the phone and called Golden Rule. And I probably wouldn’t have called the facility, I don’t know if that makes me a bad person or a good person, you’re clearly a better person than I am for having pursued it. But why, like what prompted you to do that?
You know, I know surgeons, who are, you know, working their knuckles to the grindstone and having a fight for every penny of reimbursement. And these people have just billed $13,000 for exactly five minutes’ worth of work. So that was the turning point for me, one test, they would have recouped my entire monthly salary. They were trying to reel people in off the street with their marquee saying get your COVID test here. So people might just think they were coming in for a test, but they were really getting a quote unquote, “Full Emergency Evaluation.” So someone could have walked in off the street thinking they were going to just get an antibody test and ended up with a bill like I got
David Smith 24:34
and what would you tell somebody if they had a similar situation where they saw an explanation of benefits that looked like it just was a crazy amount of money for nothing? Well, remember
Well, remember the money is coming from somewhere. Even if it’s not coming out of your pocket, it’s gonna be coming from maybe your employer’s pocket. And you know, a lot of these employers with these policies are not, we’re not talking to Google and Facebook here. We’re talking small companies. You know, nothing’s free.
Yeah, no, it’s so important. And it’s, it’s a hard thing to I think communicate because it is a bit abstract. And it’s not, you know, when you pay a bill, you watch money leave your checking account for a very specific thing. So your cost benefit analysis as a person buying something, it’s very real, it’s very tangible, it’s very present. When you see something like this, it’s not money leaving your checking account, but as you would argue very rightly, you are paying for it. All of these costs come back to us, if it’s from your employer. It’s because they’re not paying us as much compensation as they otherwise might. If it’s from government, it’s coming from taxes, if it’s from insurance, it’s coming from our premiums. And just because I can’t quantify the exact amount, and I can’t see it leaves my checking account. These are the reasons why we pay so much in all of those other areas for care that doesn’t even call us back to tell us our test results.
Zach Sussman 26:08
Exactly. Yeah, that’s 100% true.
We kind of look at this from our perspective, our vantage point is, there’s winners and losers. I’m a winner if the claim was paid. And I only have to shell out $50 or $100. And I’m a loser if the claim wasn’t paid. And I have to pay the entire amount of that procedure. But the reality in our system is that we’re all losers, because if the claim was paid. That didn’t just come from the insurance company’s money trees sitting in the parking lot. Ultimately, you paid for that. But you don’t see it that way. Because you didn’t get that bill, you will only view yourself as the winner or the loser. Not recognizing all the while that you’re really the loser that funded this entire system That creates artificial winners and losers downstream.
We’re back, with Marshall Allen.
I had to get you my top doctor award.
What is that?
I think this illustrates the facade of our healthcare system in a really interesting way.
At some point, do yourself a favor and check out Lemonada’s Instagram page for photographic evidence. But in the meantime, I’ll describe to you what Marshall is talking about. He’s holding a large plaque, just like the ones you might see at a prestigious doctor’s office. And in big bold letters, it reads Marshall Allen, top doctor.
Marshall Allen 28:10
These doctor words are ubiquitous. You go into your doctor’s office, you see these America’s best Doc’s, super doc’s, top doc’s, everybody’s a top doc, right? Well, nobody’s really measuring quality in a meaningful way. So I know that none of these awards are anything more than marketing.
Even though Marshall knew the award was basically meaningless. He was pretty excited when he got the voicemail about it.
“Dr. Allen, we just want to congratulate you on becoming a top doctor, your peers have nominated you and just call us to accept your top doctor award.” I said, well, how do I get the award, you know, because my dream was to get this plaque. I mean, I wanted this award.
There were just a few things standing in his way of getting that plaque. First, it was expensive. And Marshall being the stellar ProPublica employee that he is, didn’t think they’d appreciate him submitting a receipt for a couple $100. But he took the price down to $99. And that just left one more small issue.
I said, hey, there is just this one little problem. I’m not actually a doctor. I said, I’m a journalist. I write a lot about doctors; I write about health care. But can I still have the award? And the lady pause for a minute. And she’s like, yeah, that won’t be a problem. So you know, clearly she’s like, paid on commission, right? They went ahead and gave me the award. I paid the $99 and I got the award and then they said hey, we have to we have to put your specialty on it. You know, because are you like a top cardiologist? Are you a top Anesthesiologists? Well, so I was I’m not any of those things, obviously. So I said, how about an investigator, so I’m a top investigator. You know, the hospital that’s the best at marketing is not necessarily the best hospital, the doctor who’s the best at marketing is not necessarily the best doctor. And yet, this is the facade. This is what we’re told, we’re told that healthcare has to cost this much.
Marshall Allen 30:19
And so you just need to pay it, we’re told that the health care over here is better than the health care over here. So therefore, you’re going to pay more, you know, like the marquee brand name, medical systems in every city charge way more than other facilities. It’s not because they’re necessarily better, they’re better at marketing. They’re better at market share. But they’re not necessarily better at providing quality of health care. So I love that as a symbol, because it just illustrates that a lot of this, when you look behind the curtain, there’s really no there-there. It really is full of nothingness, looking for ways to drive up costs, looking for ways to extract money from our paychecks, in ways that aren’t justifiable at all.
With stories like this, it’s hard to have a lot of faith in the system. In the absence of price information, reviews and awards feel like the only reliable way to make good provider choices. You’re all probably familiar with billboards and magazine ads proclaiming such and such health care system rated number one in the nation. It’s scary to think that that’s all ***l. But I don’t want to make it seem like all healthcare workers are evil, fraudsters looking to make a buck. Because the truth is, we have hundreds of 1000s of nurses and doctors who are deeply passionate about helping people. I asked Sarah, where they fit into all of this.
That seems to put clinicians in between this weird rock and a hard place where on the one hand, they are their medical professionals, they’ve taken an oath, do no harm. And then on the back end, there are these business interests that they’re affiliated with, that are trying to capture as much value in those physicians interactions as possible, like, how do physicians navigate that rock in a hard place?
Sarah Kliff 32:19
I think it’s really hard. And you know, I think of like, I think of an emergency physician who’s quite busy, you know, they’re running through a lot of patients, they’re running these long shifts, I think they’re often not thinking about the billing implications of what they are doing, and understandably so, right? You know, their job is to provide good care to their patients. But I think you do have somewhat of a growing awareness, you know, among providers that, you know, the healthcare interaction doesn’t just stop when this person leaves their office, there’s going to be some kind of billing interaction later on, I think it’s even it’s challenging though for physicians to often even get information for how their services are being billed, because they’re, you know, not the ones putting in the billing codes usually.
Usually that some back-end billing administrator, they’re the ones writing up their notes, and just sending those off. And so I think it really takes a motivated physician to actually understand how their services are being billed for and what exactly that means for patients, I think, kind of the standard arrangement is you kind of do the medical care. And that’s not something you worry about. But I think I do hear from more providers who are worried about that billing implication on patients, but it takes kind of a proactive stance, I think, in a lot of healthcare systems, for them to get that information and kind of understand how their services are being billed for.
So Sarah, if we just revolutionize the system, did all the things that you and I have been talking about and thinking about in different ways for years. Who are the winners and losers? Who gets screwed in that equation? Who has the most to lose?
Yeah, I mean, I think providers have the most to lose in all of this, because if you look at what’s going on right now is they’re just making an incredible amount of money. And I’m not saying the physicians themselves, sometimes it is the people who own the hospitals or the private equity firms who have been buying up doctor practices. But the people who are getting all that money that’s being paid as bills, you know, the one six of the economy that goes into health care, the idea of any sort of reform would be to shrink that number to get it a little more in line with our pure countries. So the losers would generally be the people who are getting that money right now. The hospitals, the doctors, the drug manufacturers, would lose some amount of revenue if we do move to a system where our healthcare system isn’t as expensive as it is now.
Marshall Allen 34:53
What is morally right in America is usually determined by whether or not it makes enough money. So if something brings in enough money in the United States, then we think it must be okay because how could it be wrong when everybody’s getting rich? And so that’s kind of how I see it. It’s this idea of like the normalization of deviance, you know, where deviant behavior becomes normalized because everybody’s doing it. And it just becomes the practice. And, you know, everybody can look at each other and go, well, look, this is how revenue cycle works in hospitals and the hospital attorneys like, Well, look, they’re not paying their bills, I mean, I have to sue them, I have to come after them for this money.
And the debt collectors go, well, these are shady people that don’t pay their bills, of course, I’m going to pursue them to get the money back. And I think it has sort of metastasized not because of one person nefariously orchestrating it, in fact, it’s completely convoluted and chaotic. And that facade I talked about before the facade is that there’s any system at all, I mean, it’s just a bunch of self-centered corporations, and actors, nonprofits working to make as much money as they can.
David Smith 36:10
Part of Marshall’s solution to fixing the system involves patients advocating for themselves when these bills do show up.
We’re not trying to get out of paying our bills. But you can’t just keep abusively billing people and expect them to just keep either paying it, or getting sent to collections or sued when you can’t afford to pay it. And that’s a very common scenario, these abusive practices have been going on for decades. If we don’t snap to attention now, then we’re just being suckers.
So here’s the thing. I don’t think the medical providers look at us as walking ATM machines. However, I do believe that the system has evolved in such a way so as to justify a type of behavior for the sake of its own function. Somewhere along the way, we, we really lost ourselves in this philosophy, because in order for the system to be a certain thing, it has to make a certain amount of money to make a certain amount of money, they’ve got to engage in certain business practices. And to engage certain business practices, they have to do things that an objective viewer might view to be unsavory. Upcoding is a perfectly legal thing to do. And by the way, it’s perfectly rational thing to do. Like if you’re just looking at this as an economist, the way you’re paid, the way you’re contracted. Course, you would upcode, any one of us that worked for a business that was trying to make money. We’re gonna do whatever we can, within the confines of the law to make money.
That’s kind of our thing as Americans, but the system itself has justified its own rationale for doing it. You’re not going to convince a hospital to knock up code because it’s *** the thing to do. They know it’s the *** thing to do. It’s part of the system that they’re in. And they’ve found a way to justify that and make it work on the basis of their mission and their need to be in the community to provide a critical resource. Next week, we interrogate that logic a bit deeper. We’ll talk about the huge amounts of money brought in by so called nonprofit hospitals and hear from a woman who ended up with a million-dollar bill, when her employer, a Catholic hospital, refused to pay when her baby was born 14 weeks premature.
You know, we’re supposed to care for patients to the healing ministry of Christ, you know, treating patients with respect. So it wasn’t even a thought in my mind that they want to try and help me out if I when I reached out to them initially. And for them to be so hesitant and unwilling to help was a real slap in the face.
The COST OF CARE is a Lemonada Original. The show is produced by Jackie Danziger and Kegan Zema. Our associate producer is Giulia Hjort. Music is by Hannis Brown. Executive producers are Stephanie Wittels Wachs, Jessica Cordova Kramer and David Smith. Help others find our show by leaving us a rating and writing a review. If you have a story to share, call us at 8334-LEMONADA or send us an email at email@example.com. Follow us at @LemonadaMedia across all social platforms or find me on Twitter at @CHIDavidSmith. Lastly, we want to express our appreciation for the men and women who get up every day and work in this system with a passion for improving our health. We are grateful for the work you do. We’ll be back next week.