We submitted audit findings disputing itemized charges of $9,612 and advised our client to pay the remaining $10,897. The head of the M.H. Medical Center billing department responded by providing us with some of the missing medical records and offering to reduce the bill by $62. We told her that there were still charges of $2,573 that were unsupported by the medical records.
She sent us more medical records and increased her offer to a $647 reduction of the bill. Most of what she sent us was irrelevant; we told her that we still disputed $2,553 of unsupported charges. She sent us some more medical records, her "final offer" of a $666 reduction and a threat that she would bill the patient for the remaining $8,966.
We told her (1) that she had still given us no documentation to support charges of $2,473; (2) that if she billed the patient for charges for which she refused to provide supporting documentation, she would be committing fraud; (3) that if she mailed the bill, she would be committing mail fraud; and (4) that if she insisted on committing crimes, we, as law-abiding citizens, would do everything we could to make sure that both she and the hospital were prosecuted to the fullest extent of the law.
After absorbing that information, she told us that overcharges of $2,473 sounded about right to her and she would be pleased to sign an agreement to that effect.
• Patricia was a woman in her early forties dying of breast cancer that had spread throughout her body. She apparently prepared herself for her imminent death by withdrawing deep inside herself and completely ignoring her surroundings, which unnerved her family. They should have moved her from the local hospital where she was a patient to a hospice. If they had, she would have died quietly, peacefully and with dignity in a day or two.
Instead, they moved her to a major metropolitan hospital several hundred miles away where she was kept alive for seventeen days at a cost of over $91,000. When the doctors at C.L. Hospital finally admitted that they had just been postponing the inevitable, they asked her husband to sign a Do Not Resuscitate order. But when Patricia stopped breathing a few hours later, an attempt was made to resuscitate her anyway.
We found the circumstances of this case to be very disturbing and the sloppiness with which the bill had been prepared to be very annoying. We submitted audit findings disputing itemized charges of $25,400 and advised our client to pay the remaining $65,600.
The C.L. Hospital billing manager called us to tell us about the hospital's auditing policy. It required us to come to the hospital to audit the bill and to pay 90% of the bill before the audit would be scheduled. We told her that we wouldn't do either of those things and asked her how the hospital intended to enforce its auditing policy.
She told us that she would refer the matter to the hospital's legal counsel. That was the last we heard from anyone at the hospital. The hospital evidently preferred writing off the $25,400 rather than trying to enforce its auditing policy or defend its bill.
• Hayward was a morbidly obese sixty-year-old man with chronic obstructive pulmonary disease. He was admitted to F.S. Hospital with pneumonia, obstructive chronic bronchitis, acute respiratory failure, congestive heart failure and atrial fibrillation, among other problems. His 67-day hospital stay resulted in a bill of $138,345.
Normally, a $138,345 bill would have a huge number of errors because of multiple procedures being performed. In this case, however, the patient spent almost all of his time lying in bed, recovering from pneumonia and complaining that the food was terrible and the portions were too small.
He received pretty much the same medications and the same respiratory/pulmonary services day after day. The same sorts of laboratory tests were performed day after day. The same x-rays were taken almost every day.
We initially found overcharges of only about $1,250, but there was one charge that we couldn't figure out. Under Medical/Surgical Supplies was a $202.75 charge for MAGNUM II BA. We asked the hospital's auditor what MAGNUM II BA was, and she had to look it up. She said it was a Magnum II Bariatric Care System, whatever that is.
We discovered, after a little sleuthing on the Internet, that a Magnum II Bariatric Care System is an industrial strength bed for overweight patients. The pictures made it look like an elephant could sleep on it every day for ten years without wearing it out.
Hospitals are not allowed to charge for reusable equipment, and this mammoth bed was unquestionably reusable, so we disputed the charge. As the charge appeared in the itemized bill every day for 57 days, we disputed -- and recovered -- $11,556.75 in charges for this one item, which boosted our recovery rate for this bill considerably.
• Laurie was a woman in her mid-forties with breast cancer that had spread throughout her body. Over an eighteen-month period we audited bills for her last five hospitalizations, the last four of which were at U.M. Hospital. After the second and third hospitalizations, the medical records department at U.M. Hospital developed a strange inability to keep track of Laurie's medical records.
When the medical records for her next to last hospitalization were still missing eleven months after she had been discharged from the hospital, we advised our client to close the account on that hospitalization without paying the $8,673 bill. The hospital's auditor stumbled across the missing medical records two months later, but once an account is closed, it stays closed.
A similar scenario played out with Laurie's final hospitalization. The bill in that case was for $59,031. When the the medical records were still nowhere to be found thirteen months after Laurie had been discharged from the hospital, we advised our client to close that account, too, without paying the bill. Those medical records have never been found.
There is no question that Laurie was in the hospital both times. But self-funded health plans have a fiduciary responsibility not to pay unverified charges. Hospital bills cannot be audited, and charges cannot be verified, without the appropriate medical records. U.M. Hospital's inability to provide us with medical records in these two cases allowed us to recover $67,704 for our client. ******* We have more hospital bill auditing success stories for you to read. Better yet, have us audit your hospital bills. We do our very best to turn every bill we audit into a success story. |
