It’s A Medical Mystery

Couple flummoxed by medical bills

So a couple of weeks ago the wife (Cruella) went to the doctor for her annual “well woman checkup”. If you are a woman you know what that means. If you are a man, ask a woman, and it would be best to ask a woman who understands your tolerance for the realities of the female anatomy, to explain it to you.

Cruella checked out just fine as she knew she would. She went out and had lunch with her friends, then tootled on home and thought nothing more of it. The next week an envelope arrived from Palo Alto Medical Foundation, the medical corporation that her doctor works for. In it was a bill for the “well woman checkup” to the tune of $493. Well that’s a surprise since our Blue Cross insurance should have covered the entire amount charged for the check up.

Here’s an important thing to know about my wife. Years ago she had a thought to get into a new line of work and decided medical billing would be an interesting application of her skills. Thus she took courses and bought text books on how to “code” as they say in the biz. Code refers to the various permutations of numbers and letters that are used to define the procedure a patient comes in for (in this case a well woman checkup) and the diagnosis the doctor comes up with (she’s fine, come back in a year). Those codes are the basis on which the doctor or the corporation he works for charge your insurance company and you. Suffice it to say that even though she never actually entered that field, the information never left her head. And the textbooks became fixtures in our bookcase.

It turns out that we got this bill because instead of the visit being coded as a well woman checkup, it was coded as a well woman checkup WITH a diagnosis that something was wrong. Z01.411 versus Z01.419. I am not making these code numbers up. Getting on the phone she called the doctor’s office and was told, no we in the office coded it properly, you’ll need to call the corporate billing department to see if they changed anything.

Ah yes, welcome to the third circle of hell. When you go to the doctor at Palo Alto Med, which by the way is actually owned by a larger corporation called Sutter Health, the doctor’s office is responsible to code the reason for and result of the visit. That information is sent on to the actual Sutter Health billing department, ostensibly to double check it was billed properly, before it is sent on to your health insurance company so they can pay the bill. In order to make sure the code is correct, or perhaps to justify their code, the doctor also sends on their notes from the visit.

Oh you thought your medical records were private. How quaint.

So now Millie in billing gets to read all the doctor’s notes on your visit and can decide, nope, we gotta change this code or add in another code here because in the notes there is a mention of maybe possibly kinda sorta if I squint real hard there might be a potential problem. Thus Z01.411 becomes Z01.419. Then she ships it all off to Blue Cross happy in the knowledge she has served her corporate masters well. She kicks back, puts her feet up on the desk, takes a long sip from her martini glass and pulls out a Kool Menthol to celebrate her achievement. That’s assuming she redid the coding in an honest attempt to be as correct as possible.

Thing is, Sutter Health is actually kinda known for not being the most reputable when it comes to doing honest coding. To the tune of a $90 million dollar fine by the federal government.

Does that have you intrigued? Click the link below to continue on

We’ll get to that fine in a moment, but first let me get the wife out of the third circle of hell.

The reason she got this bill for $493 was that because the visit’s coding had been changed it was now considered NOT a well woman checkup but a diagnostic checkup. Blue Cross doesn’t cover that (why it doesn’t is another story for another time). So Blue Cross kicked it back to Sutter Health who kicked it back to the wife and told her to cough up the $493. She ended up having to go through the Blue Cross fifth circle of hell to reach Manuela in the Philippines who corrected the coding and sent Sutter Health their $372 and showed the bill as paid in full.

$372? What happened to it being $493?

Well the lower amount is the negotiated rate that is in the contract between Sutter Health and Blue Cross as to what they will pay for a well woman checkup. The higher rate is what Sutter Health charges if you don’t have insurance. Doesn’t seem fair does it that someone walking in off the street with cash in hand for services rendered has to pay more than the insurance company that wines and dines and slips a little something to the execs of a major health care company. Welcome to medicine in America circa 2022.

Now back to that $90 million fine Sutter Health paid.

They got caught with their hand in the proverbial cookie jar back about three years ago. The entire story can be scrutinized here, but the gist of it is that Millie in billing was not just making sure her company got paid it’s due and fair. It seems that Millie was changing codes for Medicare patients so that the US government, i.e. the taxpayer, was paying for diagnoses that in fact were not what the patient had presented with and in all cases were billed at a higher amount than what was actually owed. Consequently I imagine the lid is pretty tight on any Medicare claim around old Palo Alto Medical these days. Any coding headed for the Medicare bin is probably double if not triple checked.

But now they have to make up that $90 million, plus what I’m sure is the three or four times that amount they actually were overbilling and now can’t (at least for the moment). So they are taking the opportunity to start sticking it to those of us too young to be on Medicare. Well, actually I’d be willing to bet they’ve been sticking it to us for years, over charging or changing coding to overcharge. I mean if they can do it to Uncle Sam they can certainly do it to Cruella.

Here’s the thing, they have been doing it because we as a society have allowed them to get away with it. Come on, admit it, how many times have you gotten the EOB (Explanation of Benefits) and looked ONLY at the bottom figure of what you owe. “Oh, I only owe $140, fine, let me send them a check”. Did you actually read the EOB to see if you are paying what you should actually be paying? Survey says…probably not. And even if you did read the EOB, could you truly understand it? And even if you couldn’t understand it and decided to call the fifth circle of hell that is your insurance company “help” line, how often did you give up after 90 minutes of Muzak while on hold because “your call is very important to us”?

This is how they do it. This is how Sutter Health, a so called tax exempt non-profit corporation, can afford to pay $30 million in salary to their top executives in 2018, the last year we have data for them. Or how they were able to pay $137 million to Rightsourcing Inc for basically being their HR department. Or how they were able to pay $224 million to Herrero Partners for construction services as well as Rudolph and Sletten a paltry $36 million for more construction services.

Before you start feeling smug that you don’t use Sutter Health for your medical needs, just remember they are no better or worse than any of the many other medical corporations that have desecrated the American financial landscape with their vulture like hunger. As a matter of fact, Sutter Health doesn’t even crack the top ten in money earned. I wouldn’t be surprised if the Little Sisters of the Poor had Sister Millie down in the basement messing with billing codes while everyone was upstairs playing Bingo.

There are a lot of things you can make a lot of money off of in this world. Invent a better car, build solar panels for peoples’ houses, create the “next big thing” in tech, whatever. The one thing you should not be able to get rich off of is another person’s health. No one has the right to do that. Yes, pay the medical professionals, the doctors and nurses and techs who studied for years to be able to diagnose and treat other human beings, a better than fair salary. But the leeches who attach themselves to the healthcare system, the CEOs and the consultants and the management executives who clog the system with their unnecessary claptrap and then devise ways to game the system to enrich themselves, these people need to be weeded out. The only way that can be done is to blow the system up and start all over. The starting point should be Medicare For All. Full on socialized medicine would be the ultimate goal.

And to anyone who says “I don’t want the government telling me what kind of medical care I can get” let me ask this one question: How is it better to have a for profit private corporation, whose interests are in making more money by not okaying a potential life saving procedure for you, telling you what kind of medical care you can get? Their best interest is in bleeding you dry financially then tossing you out so they have a bed open for the next sucker.

Millie will make sure of that.

Here’s 10cc, the wittiest rock band to ever exist, with their Hospital Song to take us home with a list of does and don’ts for your recovery


Shapiro Out

PS If the cost of healthcare is an issue for you let me steer you to a podcast called An Arm And A Leg which does fantastic work on that subject. Not only is it informative, but it is highly engaging and entertaining. 



2 thoughts on “It’s A Medical Mystery

  1. Its called “up-coding”. Illegal, but only if you get caught. Good luck wth that. This little coding sleight of hand got worse with roll out of ICD-10, ten or so years ago. You know much more than avg patient, but billing & coding Byzantine by design, ostensibly for a dozen other reasons. I was a nurse practitioner back in the dark ages of paper charting. Retired right around time most practices and hospitals literally came online with EHR and all this coding nonsense. It was nightmarish frustrating and sad.

  2. Cruella here – well whaddaya know….I check my balance due this morning and it’s zero. It seems that somehow this all got straightened out yesterday. Go figure.

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