anyone dealt with Medical Over Billing?

also, any chance you've photographed the injury? is it worth seeing your wife's gp for a documented opinion?

we have her medical files in hand now which detail exactly the nature of the injury.

1cm, straight cut, no layered sutures, no debridment required. simple closure. 20 mins total time according to the signed file.

wow that's $24.08 a sec! Not bad!!! (doesn't include what you paid at the hospital because I don't know that figure) I wonder how much of the 20 mins he was actually there at your wife's side? In case you were wondering that's $86,688 an hour for a 1cm cut that didn't require a plastic surgeon's attention. Disgusting.

In case you were wondering that's $86,688 an hour

well, medical schools are pretty expensive....

From the math I did, his entire education could be paid for by 30 stitches. That's pretty good.

This has been a HUGE education for me. There's a term in the medical (and insurance) industry called 'usual, reasonable and customary' that dictates what a doctor can expect to get for his services. A doctor can charge whatever he/she likes but if its nowhere near usual, reasonable and customary - they can't come after you to pay it.

Here's a couple of of resources ALL of you should know whenever you pay ANY medical or dental bill.

1) Get a copy of what is submitted to the insurance company - NOT the bill post insurance but the actual bill from the doctor (they are required to provide it to you on request). Also get a copy of your medical records from any given procedures.

2) On your bill are two types of codes that determine how your bill will look: the Diagnostic Code (ICD9) and the Procedure Code (CPT). One is a record of what was wrong (the diagnostic code) and the other is a record of what was done to correct what was diagnosed (CPT).

3) Take your CPT codes to this website:

http://www.fairhealthconsumer.org/

It has database of codes and can tell you how much, on average, you should have to pay out of pocket -- specific to YOUR zip code (stitches in NYC being more expensive that stitches in Des Moines) You're limited to 20 or so look ups a month on the 'free' service but its enough to get a sense and give you the confidence to argue with the billing people and not feel like you're in the dark.

4) Check your CPT codes (and what they mean) against your medical record. There's an unethical but common practice called 'upcoding'. Imagine you go to the ER for a cut on your forehead. When your CPT codes get recorded, they have a portion of the # that tells how severe the cut was. The more severe, the more the doctor can bill. So, if the more severe codes mean more money, guess how often you see CPT codes for the least severe type of cuts? Never. They always get upcoded to make more $$.

In my wife's case there's an element of fraud because guidelines dictate that a code of 13131 must be 1.2-3cm in size but her chart says it was a 1cm wound. So the guy upcoded and now it's documented.

There's also a thing called 'unbundling' that is not allowed and it looks something like this:

Let's say I bill you for 'Mailing a letter to my niece.' and that costs $5. Fair enough, but included in Mailing a letter to my niece are a number of services that I cannot ALSO bill you for. The cost of a stamp, the getting of an envelope, the wear and tear on my pen.

In my wife's case, the doctor billed us $15,000 for 5 stitches. But he ALSO billed us $5500 for 'exploring the wound' - which is an unbundling because you HAVE TO explore a would to suture it so it should be included in that $15,000 cost.

Okay that's it for now. More as I learn more.

small update. I sent a letter to the President and CEO of NY Methodist Hospital regarding the bill - one of the better letters I've written, imho. he got back to me 18 hours later saying he was summoning this doctor to meet with the head of surgery and the head of plastic surgery to explain himself and to insist that the bill be dismissed.

I also ran into an old friend who, it turns out, writes for the Wall Street Journal and volunteered to do a story on this case. I'm weighing my options, might be time to dial back the pressure. But it's rewarding to see that you can, in fact, fight back.

That's great AC!

I'm weighing my options, might be time to dial back the pressure.

NEVER!! You got him on the ropes AC, go for that KO blow! HE MUST BE SACRIFICED SO THAT OTHERS MAY LEARN!

I'm with Carl.

and congrats!

It would make a good end to the news story, don't you think? fighting back works!

I am w/Carl and Zero on this...do NOT dial down the pressure...keep it going. It will be probably be the ONLY way that this so-called Doctor will get what is coming to him and MAYBE cause others that are doing the same to stop taking advantage of others. This NEEDS to come to light and the people NEED to know. This kind of behavior should NOT be dismissed nor should it be allowed to quietly go away...this MUST be exposed. So please AC...see it to its conclusion and educate the masses using the power of media that you have...the public WILL thank you.

I understand the urge to stick it to this one guy but I think dialing it back a bit wouldn't be the worst thing in the world. He's going to get a serious reaming from his bosses already and most likely be fired. That seems like enough punishment for him, especially if he was only doing what "everybody else does".

That said, I would certainly continue with whatever news stories you can get done on the problem in general. The issue is wider than this one guy and making the public aware of it and hopefully giving them tools to combat it is well worthwhile.

Hope that makes some sort of sense.

The MAIN purpose of a Wall Street Journal story would simply be the moment the reporter calls the doctor for a comment. It's that moment of pressure and pain I'd be going for and, at this point, it doesn't look like a I need it.

If my reporter friend wants to write in general terms about how to analyze a medical bill and how to proceed if you think you've been overbilled, I think that's a great community service. I'm writing a piece about it now (for my blog) that is really a step by step guide to reading your bill, understanding it and fighting back when needed.

sounds like you have all the bases covered. Hopefully your article sees wide circulation.

Pretty amazing story AC. While it appears you have prevailed, I wonder how many other families are under duress from this doctor's behavior? The advantage of continuing to press might result in the hospital reviewing this doctors recent billing practices, and perhaps uncover some other families that were not savvy enough to dig into the system and stand up for themselves.

Thanks for the education!

...also pursuing this piece might bring to light more than this one doc at this hospital doing the same thing...who know what this snowball may start?

OK, I guess I'll jump in since I get to work with a lot of docs in the hospital. I'll say this, I don't believe that this doctor did this on purpose. I just can't believe that any MD would think this type of behavior would be acceptable or that they would get away with it. The "upcoding" does sound likely but this is beyond scaling up a diagnosis.
My question is why does this hospital have their doctors doing their own billing? That seems unusual to me and I'll bet that is part of the problem. Of course there are a lot of inconsistencies in how we are collecting medical costs which is part of the reason we needed reform. A single ER doctor might see 40 or 50 patients in a day, many of whom have very complicated presentations. There is a ton of documentation and behind the scenes stuff going on and to place the billing responsibility on them as well is asking for more mix-ups and trouble. I know some brilliant doctors but they were trained in medicine not business and I could totally see some of them saving someone's life and then screwing up the bill afterward. Even the docs in private practice usually have people in the office who manage this stuff for them.

I look forward to hearing what explanation, if any, they finally offer up to you. I think it is a good idea to pursue this story if you have that option but not for the reason of burning this guy at the stake. He may very well be a dedicated physician who simply effed up your bill. Do it to get to the truth.

Update:

Got a call from the NY Methodist CEO. He said the head of medicine and the head of plastic surgery sat down with Dr. Mir (he of the $26,000 bill). The CEO said the doctor gave a "long and very convoluted explanation of his billing". The hospital has removed his privileges from seeing patients in the ER and they will remain revoked until the doctor "becomes more modern in his thinking and less aggressive in his billing". The bill has been zeroed out and we are not asked to pay anything at all.

Ross, the doctor wasn't staff at the hospital, he was a guy with privileges who HAPPENED to be in the ER that night seeing another patient. So when they NEED a plastics specialist he was a guy on a list that they used sometimes. My wife didn't need him but he was there and - I would guess - saw an iphone and a nice address in a nice part of town on her chart and decided she'd have good insurance and probably some $$ to spare. (that's a guess, of course)

He no longer has the right to work in their ER which is good. I wanted the bill gone but I also wanted this guy to have to think twice next time he wrote a ridiculous bill - I hope that's the outcome.

That's good AC. I hope the outcome is included in the news story. Well done!

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That's great AC, I'm glad it worked out. Make sure you keep records of their commitment to zero out the bill in case someone develops amnesia about it...

That's great AC, I'm glad it worked out. Make sure you keep records of their commitment to zero out the bill in case someone develops amnesia about it...

Yeah, I'll do that. I think, however, that because his future livelihood is dependent on me not re-contacting the CEO of NY Methodist, I'm safe on that one.

Good to see this resolved, and that justice is served. ...this Dr. Mir sounds like an crook...glad to hear that the Hospital has taken away his rights for ER work. Hell, if I got that kind of money for throwing stitches in, I would be VERY HAPPILY retired right now.

GRATS! Hopefully the hospital also reports him to the applicable medical board. It's not medical malpractice but it is definitely unethical and possibly illegal so it should be documented somewhere centralized if/when other complaints are made.

I wonder how many times he has done this before, or if he (luckily) got caught the first time he tried it?

I love how Dr Mir just let the $26k slide...you'd think the guy would fight for the money he's owed for work performed?

http://swampland.time.com/2013/05/08/an ... g-secrecy/

http://swampland.time.com/2013/05/08/an-end-to-medical-billing-secrecy/

Saw this guy interviewed on Charlie Rose and it was insightful but depressing to know the state of our medical [billing] system. We all should just will all of our money away to insurance and healthcare companies when we reach our golden years as they're gonna take it anyways.

I would say that I'm looking forward to seeing this covered in the news, but I know better. Jodi Arias updates are far more profitable.