In any other industry, emergency medical billing would be considered fraudulent

Last summer, MD/journalist Elisabeth Rosenthal's husband had a bike accident and was seriously injured and taken by ambulance to an emergency room.

Rosenthal's description of what happened next is a compact and infuriating statement of how grifty and crooked America's health-care system is, based on a set of lobbyist-legalized billing practices (ushered in under cover of 9/11) that would be considered fraud in any other industry.

Rosenthal isn't talking about being billed thousand-percent markups on slings or over-the-counter medicines, either. That's just price-gouging. She's talking about massive bills for services that were never delivered, in a way that is, again, totally legal (thanks to intensive lobbying by the emergency medicine industry).

For example: her husband was given a neck-brace (billed at $319) but after it was determined that he didn't need it, the EMTs removed it and kept it. Nevertheless, he was billed for the full price, as though he had walked away with it (perhaps thrifty cyclists could keep these neck-braces in their panniers so that EMTs could use that, saving them money, if they get into an accident). The final bill for a one-hour loan of a piece of hard plastic was $215, with $24 passed on to the Rosenthals as a "patient responsibility."

Then there's the "cover charge" -- the farcical fees levied for just setting foot in the ER -- $3,400 for the ER and another $1,030 for the trauma surgeon.

Though Rosenthal's husband had a single CT scan, they were billed for five scans ($1,400-$3,300) because the radiologist looked at five different places on that scan after it was complete.

They were also billed for consultations with senior doctors who never examined Rosenthal's husband: instead, they were tended to by residents, who were billed at their boss's rates (unlike lawyers, who have one rate for partners and another for juniors, emergency room docs get to bill for their trainees as "extenders," charging the same rate for their time as if the great doc themself was on the job). That bill: $1,512.

They were billed for an exit interview with a PT that listed fraudulent items (walking the patient 10 steps with a stabilizing belt) and came with a charge of $615 for what amounted to a quick checklist rundown noting that Rosenthal's husband was injured in all the places that he already knew that he was injured in.

After Rosenthal's husband was discharged, he got a series of cold-calls from a private physiotherapy company affiliated with the hospital, who repeatedly sent PTs to his home despite that fact that each one that arrived agreed that it was too early to start PT. This happened after the Rosenthals told the PTs they didn't want this service. (They were billed for four PT sessions)

Then, when Rosenthal's husband needed his pain med prescription refilled, the hospital docs told him he'd have to come back to the ER because the trauma clinic was only open for six hours a week. Walking into the ER to get the doc to sign a prescription triggered another ER cover charge of $1,330. They were also charged for "surgery" when Rosenthal's husband had his finger splint adjusted (someone cut some of the tape away and re-taped it) (more than $900!).

Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because it’s not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern about your well-being, as one benefits manager enlightened me: They’re “too big to care about you.” Electronic records, which auto-fill billing boxes, have probably made things worse. For example, the birth of a baby boy may automatically prompt a bill for a circumcision; having day surgery may prompt a check for sedation.

So what is the appropriate payment for swag I didn’t ask for, outrageous cover charges, stand-in doctors, drive-by visits and faux surgery? In some cases, zero; in others, far less than was paid. And yet, these are all everyday, normal experiences in today’s health care system, and they may be perfectly legal. If we want to tame the costs in our $3 trillion health system, we’ve got to rein in this behavior, which is fraud by any other name.

Where the Frauds Are All Legal [Elisabeth Rosenthal/New York Times]

(via Naked Capitalism)