In Joseph O’Neill’s novel Netherland, Dutch protagonist Hans commented that he is “precluded by nationality from commenting on any place other than Holland.” My experience is slightly different. As a foreigner living in America, if it is desirable for me to comment on anything, it is often to provide “a fresh pair of eyes” to look at issues and problems that locals do not see or care about any more. Now you have been warned, let my rant begin.
Recently my fresh eyes were focused on medical billing. My wife had a procedure removing a kidney stone less than 6 mm in diameter. The stone was discovered last December and naturally it caused much pain. She went to her primary care doctor, who referred her to a specialist, who referred her to take a CT Scan. The stone was discovered and prescriptions were given. It didn’t work. Pain returned in February. She went to the specialist again, who referred her to yet another CT scan, and then a “small procedure” was scheduled and performed. The stone was sent to a lab for analysis. We have heard no more about the analysis, while the bills, explanations of benefits and threats about sending collection agencies started to trickle in. These bills came from the primary care doctor, the specialist, the hospital, the radiologist, the anesthesiologist, and some other doctors whose names we did not even recognize. I wonder if we were billed for a nod or “hi” in the lobby. The bills do not seem to reflect what the insurance company says about the expenses. For the treatment, the insurance company may say that the “allowed amount” is 5100 dollars while the hospital’s bill indicates the total charge is 6500 dollars.
The entire treatment, together with the two CT scans, cost over 16,000 dollars, higher than what some people pay for childbirth. Having a kidney stone is often said to be worse than giving birth, but I didn’t know that this statement has financial implication as well. The insurance paid a substantial amount, but it still left us with around two thousand dollars' worth of out-of-pocket expenses spanning two insurance billing years. That stone sounds like a diamond.
Puzzled, I checked with the Healthcare Blue Book, an online advisory resource that provides a benchmark for various medical expenses. The site indicates that the cost should be a few thousand at most.
It is more difficult than what one might normally think to find out where it went wrong. The bills were all written in highly specialized language to prevent any sense making by the ordinary. English professor Dr. Carol Johnson of New Jersey recently wrote an award-winning book called the Language of Work investigating the discourse people use in a specific field. In the book she quoted Foucault as saying “discourse communities create their own rules of formation and prohibit areas of inquiry,” or any inquiries in the first place. For instance, instead of "kidney stone", all the documentation insists on using the word "calculi", which makes one wonder if it requires a degree in linguistics to become a patient.
So with respect to the professionals, I brought the issue to the specialist who ordered and performed the procedure. He simply said he didn’t know anything about billing. I started to call to make some inquiries. I tried first with the insurance company, to no avail. The man answering the phone didn’t have the slightest idea why there was a discrepancy. He was putting me on hold for so many times and so long each time that it eventually became obvious that he just wanted me to give up.
I called the medical billing office, and found that each bill has a separate account number even if you were there for the same treatment. “We have to,” the lady explained, “Otherwise the insurance company wouldn’t take it.” That means you would need to repeat your information all over again every time you call. The National Public Radio (NPR) recently reports that it is for a similar reason some people have lost their homes. Every time a homeowner makes a phone call to the mortgage bank, a new person answers the phone and has no idea of earlier conversations that could have helped a homeowner save the home. In a country where Netflix can predict the kind of movies you would like to watch next, where Amazon can remind you the book you should be buying, where Turbotax can carry over all your information from a previous tax year, why cannot a bank have a way to record earlier exchanges of information? Why cannot an insurance company or billing office generate a consolidated bill in more accessbile language? I understand that the world does not always operate by customers’ perception of things, but it still is asking customers too much to obey service providers’ silly little rules that probably originated from their own inefficiencies, for instance, in dealing with multiple claims.
As there were six to seven such bills, each with a new account number, I could easily lose two whole hours on the phone in such paralyzing, circular and fruitless conversations that basically conclude in one message: that nothing is wrong with anything because this is the way we do things here. I heard what was left unsaid and I began to understand why medical tourism is gaining popularity.
Billing in the healthcare industry is so riddled with problems and secrets that medical billing became a profession that vocational training schools heavily advertise those days. Even with such professionals on board, I found that the left hand still does not know what the right hand is doing. Nobody can provide any straight, useful answers whenever there are cracks between professional turfs. As you sit in front of your pile of paper, you begin to conclude that the only way out is to hire another professional to deal with the bills. In most cases, however, the task falls on the shoulders of the patient or the patient’s family, while they have some illness or recovery to handle in the meantime.
Each country has its own healthcare problems, and America is probably the best country to be sick in, especially for the rich who wouldn't need to care about the cost and the very poor who wouldn't need to pay. Yet it can easily turn into a nightmare for those who are inconveniently ranged in the middle. I suspect that the common denominators of most issues are human greed and indifference, though such qualities can manifest themselves in totally different ways. Inefficiencies may have come from specialization carried to an extreme. The industry and its professionals care more about their professional boundaries than what makes sense to the patient as a whole person. For instance, most medical insurance plans do not cover dental and vision problems simply because these are more expensive treatments. Aren’t teeth and eyes body parts?
In the dire state of extreme compartmentization in the system, an unsuspecting patient is being sent around to labs for expensive checkups, some of which are meant mainly as extra caution against possible claims of malpractice. In other words, ordinary patients are punished for other people’s frivolous lawsuits or people who end up not paying anything. To cover the cost, they sent inflated bills. How is that supposed to be right? Would your neighborhood association rob your neighbor to pay your utility bill? If your neighbor wants to do that of his or her accord, that's a whole different issue.
Medical billing seems to have been designed to produce rather than correct errors, generate rather than eliminate confusion. When there is an error in the billing, then good luck getting it fixed in your lifetime. Common sense tells us that a system will start to go bad if good behavior is being punished and a bad one is rewarded. Given the size of the problems which we can all experience on an individual level, no wonder healthcare makes such good political debates.
Compared to the greater issues in the healthcare industry, medical billing may be a small problem. Is it really that difficult to fix, or is it mercy by the healthcare professions, to make one feel that by comparison, the original illness is a smaller issue to deal with?
