Rooting Out Fraud Part 3: Billing Abuse by an Anesthesia Group

October 14, 2009
Jeff Kaplan

I was out of town on business and had a 'slip & fall.' After many tries and many hours on the phone, Oxford could not direct us to a plan orthopedist—hand surgeon? Yes; Foot and ankle? Didn't happen. Ironically (or was it?), that bureaucratic hurdle saved them a bundle.

I was out of town on business and had a 'slip & fall.' After many tries and many hours on the phone, Oxford could not direct us to a plan orthopedist—hand surgeon? Yes; Foot and ankle? Didn't happen. Ironically (or was it?), that bureaucratic hurdle saved them a bundle. I didn't want to go to an ER if I didn't have to, but the unintelligent HMO would have gladly paid that tab. Instead, I went to a friend of a friend who was out of network; I would fight with the insurance despots, later.

Ten days passed. I went to an orthopedist acquaintance that practices where I work. He repaired the fibula fracture at a local hospital using a participating anesthesia group. The health insurer was "protected" by my $1,000 deductible—hardly enough in this day and age when this rather straightforward surgery is so expensive and even more so when the wound wouldn't close. V.A.C. therapy was ordered; it sucks the living blood and shmutz out of the wound at 150mmHg, 24 hours a day for over a month. (Not fun, but it worked; a bargain at $2,722.87.) I also "needed" a $350 knee walker so I could get back to work (we only get 5 sick days)—not covered. I got an earful from the wound therapy specialist about what insurance companies will and will not cover in the name of "health" insurance, but that's for another time. [Pity the poor patient!]

Returning to the anesthesia group, they were par and under obligation to the hospital. For a former medical director like me—that meant no 'balance billing.' More than once, they apologized for being caught with their pants down; nevertheless, they keep sending us bills. We're still fighting them, but I'll let my wife tell that part of the story...

"Upon receiving a bill for over $1700 from the anesthesiologist for my husband's surgery and a bill for my cataract surgery for close to $1,000 (I was asleep for 20 minutes), I took it upon myself to investigate these charges. The Oxford representative was extremely helpful. She made phone calls to the anesthesiologist's billing office on my behalf; only to find out that our combined out of pocket expenses will be less that $150."

Where does Jane Doe go when hit huge expenses, especially when she does not know her rights? My wife, an advocate who works with a national organization that is helping patients negotiate the healthcare system, says: "Believe me, many patients never know that there is a customer service number on the back of their insurance card and that they have a right to ask questions, even when they don't understand the lingo. How would John Doe know to call the insurance company when the medical and surgical charges have been inflated beyond rationality [Ed Comment: as part of the game of building a higher financial profile for the doctor and his heirs]?

And, does the insurance company learn, appreciate or care that they are interfering with good medical practices? Not often, but when they do, I'd like to know what do they do about it!