Did You Know?

Hello everyone.

Today I would like to alert you to a new way that my local hospital bilked us out of money.

I moved here a year and ½ ago. My new PCP provided me with referrals to other doctors. One such referral was to a rheumatologist because I needed a shot to prevent osteoporosis. The shot and office visit had always been paid in full by my insurance in the past. You know what’s coming – this time it wasn’t covered.

As a matter of fact, I was billed twice. I paid the co-pay for the doctor, about $25. I received another bill from the hospital, asking for a co-pay of $50. I couldn’t understand what the charge was for, and the hospital billing department insisted that it was due.

I called Medicare. They never heard of such a thing, and looked up bills for the same procedure in years past. I’ve had the same shot and medicine for many years. Not only had it been covered, but Medicare informed me that the medication was over $1000 more expensive than last year. She couldn’t understand why.

Then I called my secondary insurance. They couldn’t explain it either. Looking at the bill, I was informed that Medicare and my secondary insurance had paid the doctors bill, with the co-pay balance of $25. They also paid the hospital about $741 between the 2 of them, with the balance of $50 from a co-pay do for me.

But my insurance didn’t know what the charge was for. They thought maybe it was a coding error on the part of the hospital.

In case you didn’t know, I am totally blind. Which means I record important information such as this. The following is a verbatim conversation I had with the billing department at the local hospital:

Number 1.  A Medicare rep told me that if the hospital owns the clinic in which the doctor’s office is located, the clinic must bill also. The doctor bills Medicare part B, the hospital bills part A, because it’s part of a clinic. So, the patient is stuck with the co-pay from the hospital even though I didn’t go to the hospital, I just went to an office in the hospital.               

Number 2.  So patient is responsible for 2 co-payments, one for the doctor and one for the hospital, because the charge is strictly where the hospital owns the clinic in which the doctor’s office is located.

Number 3.  Another rep put it this way – sometimes, when you receive services in the hospital where your doctor’s office is located, you’ll receive statements, one from the doctor and one from the hospital. This is especially true for something like a bypass, x-ray, anesthesia, Dr. services or part B, hospital services are part A. Medicare pays 80%, secondary insurance pays 20% of the remaining 20%.

However, she went on to explain that I shouldn’t have received the co-pay. Because it had been paid for 80% by Medicare, 20% by the supplemental insurance. Even if it’s an outpatient clinic.

Now wait till you hear the hospitals billing department response:

Number 3. We are unique because we are a hospital and also a clinic. There are outside clinics not connected with the main hospital. If you go to the other clinic, you’re not charged co-pay. If you go to the doctor’s office in the hospital, Medicare requires us to always file a separate bill for the hospital charge. Medicare considers this unique because we’re a hospital but we also have outside clinics. So Medicare always requires us to separate the clinic fee from the doctor fee.

He then went on to say that if I didn’t have Medicare that everything would be on one bill, but Medicare was the one that required that the bill be split into two, one for the doctor and one for the clinic.

When I told him that Medicare never heard of this, he said “Well, if there’d been a discrepancy Medicare would’ve caught it before now.” That they’d always billed this way. He also told me that Medicare paid about $1063.01 and my secondary insurance paid about $265. This is just for the hospital/clinic supposed visit. My secondary insurance paid $215 so I was left of the balance of $50 for the co-pay.

Number 4.  Another rep from the insurance company informed me that the doctor billed for an office visit co-pay was paid by me. But the Dr. used medicine that he received from the hospitals pharmacy so therefore the hospital charged me for use of its facility and its medicine which is always higher because you’re buying a service from the hospital. He said it’s like the difference between getting a walker from the hospital when you leave it or buying it at Walmart. You’re always paying a higher fee from the hospital. He said this is a unique situation that most people don’t know about. To avoid charges like this in the future, go to a doctor who has a standalone office and is not in a hospital or clinic.

I finally received the answers from a local SHIP (state health insurance program) office. Every state has one – an example is FLSHIP for the one in Florida, etc. the state abbreviation goes 1^st. The representative explained that the doctors coming out of medical school don’t want to pay for medical malpractice insurance, office space, bookkeeping, etc. So, the hospitals started offering office space with in their hospital to the doctor. This way, the hospital covered the expenses for the doctor, who in turn, paid rent to the hospital. This allows the hospital to charge the insurance company for a hospital/clinic visit. They can also charge for equipment, medication, etc. at a higher hospital rate. And the cost is passed on to the patient.

Well, this is one reason why Medicare may go broke earlier than later. And I’m sorry that I took so long to explain it but I wanted to be absolutely clear. Because it was difficult for me to understand, even with the recordings I made.

The bottom line is, don’t go to the hospital until it’s absolutely necessary. Find a doctor whose office is standalone, not in a hospital or clinic. I told the doctor that I was changing because I didn’t want to pay the hospital fee, and the doctor’s office informed me they had no idea the hospital was doing this.

Hey, if I don’t tell you these things, who will? And I’m sure you have some great stories out there as well.

As always, be safe, wash your hands, and where your mask. And check your bills!

Enjoy the day, Deb