The danger of visiting an ER, financial and medical

Highway Robbery: 2: excessive profit or advantage derived from a business transaction Merriam-Webster
(Tip: when visiting an unknown medical facility, get as much video documentation as possible of any interactions with the staff)

This is a story of our experience with how bad the U.S. health care system is and the corruption involved. I will begin with the conclusion: we visited an ER and were lied to at every step of the way and were severely ripped off by a medical institution and there was no interest by any governing bodies to do look into illegalities, including using an imposter and billing with a real doctor's license.

Visit
Noel had some severe abdominal pains on 12/26/2017 after minor pains the previous few days. It was to the point that we thought it wise to get it checked out and headed to our usual Urgent Care clinic. We told them that it may be a kidney stone, which she had two times previously, and they told us we needed to go to an ER as they could not help us if indeed that was the problem. Not being prepared, we visited an Urgent Care and they said that if it was a kidney stone that we would need to go to an ER and there was one down the street. This was Dignity Health Arizona General Hospital at 44th and Chandler in Ahwatukee. It looked like a large clinic and we were surprised at how strangely empty the parking lot was.

We approached the receptionist and told her that Noel had severe abdominal pains, that it may be a kidney stone, and asked how much it might cost as we had no insurance. We were told that since they could not predict the various services that would be performed, that it would be impossible to give us an estimate. Without knowing the severity of Noel's condition, if it might be life threatening, we made the decision to trust the medical facility. This turned out to be a major error.

This ER's methodology is to always do a cat scan for abdominal pain along with a blood test (as I was told later by the ER staff). This triggers several expenses that the receptionist was well aware of, but refused to disclose, all the while knowing the costs via their chargemaster pricing in their computer. Strangely, the detailed 4 page Clinical Report did not include the Cat Scan procedure and Noel was surprised that it only took very little time to slide in and almost immediately out of the machine with just one pass with no change in clothing or removal of jewelry. Supposedly the scan showed a 17mm kidney stone that was not blocking, gall stones, and it was determined her pain was due to acute diverticulitus of the colon with bleeding along with an acute urinary tract infection. Diverticulitus occurs in 50% of people over age 60 and only exhibits symptoms if infection and inflammation occur; it is treated with a short course of antibiotics. While waiting for the scan results, Noel was shifting her neck to relieve some pain she constantly has since an accident she had as a teenager and the RN said that she would need to have an EKG for that which they immediately administered. After the doctor explained she had diverticulitus for which they administered an IV drip. Surprisingly, the drip seemed to take too long and at the end of our visit, they spent about 5 minutes squeezing the bags that were previously hanging in order to get the job done quicker and make their room available again. Her arm was in pain for several days from this pressure, so I wonder if this is an allowed practice just to clear the room up for other patients.

Billing
We were charged $1,472.00 and paid the full amount on our credit card before leaving the ER. We were told that we would be receiving other bills, but they would not give us any idea as to what the amounts would be. We should have been suspicious when they also gave us a "Summary of Financial Assistance Programs" sheet. We also received a 4 page Clinical Report that said the RN assessed the acuity at LEVEL 3 (13:15).
 
Clinical Report. 
 
Original Billing on day of service. 
 
Credit Card receipt. 
 
Financial Assistance. 

Lionel, Noel's husband, had been to Urgent Care on 12/24/2017 for the Flu, so that cost of $145.00 added to this made it an expensive couple of days. We had no idea what we were in for. Later, Lionel was still not feeling healed, so he visited a local clinic for a physical, which included blood work and an EKG; the total cost was $200 including labs and analysis.

About a week and a half after Noel's ER visit, we got a bill from Dignity Health, stating that we owed a balance of $3040.00 (statement date 1/3/2108). There was no itemization included. It just stated that we had paid $1472.00 and the current account balance was an additional $3040.00. Of course it included a phone number, which goes to a separate accounting firm and they said that they would contact the hospital and have them send us an itemized bill (this turns out to be their first response on any call). While waiting for the itemization, we received a Radiology bill for $427.02 (statement date 1/17/2018) and a Medical Professionals bill for $1002.00 (statement date 1/17/2018.
 
First Facility Bill. 
 
Radiology Bill. 
 
Physicians Bill. 

Then we got a revised ER Hospital bill which said our new current account balance was $7720.00 (statement date 1/31/18), which meant our total out of pocket for a tummy ache and anti-biotics had grown to a total of $10,627.02.
 
Second Facility Bill. 

The itemization was issued on 1/25/2018 and arrived in early February. We took this to the ER and got some explanations. According to the receptionist at their facility, any stomach pains trigger an examination via a CT scan. The CT ABD/PEL WO CT scan was $2541.
We were told by the billing department that any time a CT scan is part of the procedure, it raises the acuity level to LEVEL 5, the highest level on their scale (even though our Clinical Report stated LEVEL 3). An ER LEVEL 5 hospital charge is $3,381.
Although most all of our time was spent with an RN or technician, there is a separate doctor's fee of $927, which we were told the amount is based on a Level 5 level of care. Thus even before any analysis or treatment is administered, the bill will be a minimum of $6,849 just by stating that your stomach hurts.
The EKG, which was totally unnecessary for the reported symptoms, was $492 plus a $75 charge on the doctor's bill for interpretation.
 
Itemized charges. 
 
Itemized summary. 
 
Physicians Itemization. 


Disputing Charges
When discussing the charges of the bill with the ER staff a month after the ER visit, I asked why they wouldn't inform us of these basic charges that were extremely high. I spent most of my time with a woman who said she specialized in medical accounting at school and her primary response was that if we judged the fees to high, we might not receive treatment, and then the ER would be liable for not administering care. Another man in the office said that it was against HIPPA regulations to divulge pricing. Both of these statements are incredulously false. I told her that Arizona Law requires that we be shown rates upon request and provide a comparison to other regional hospitals. She said that all the prices are in the computer and she couldn't show us the computer. HIPPA regulations actually address the saving, accessing and sharing of medical and personal information of any individual and have nothing to do with sharing costs with a hospital's client.

After the fact, it becomes easier to see a pattern of behavior to make false statements to delay further actions until the client has fallen so far behind that the only recourse is to surrender. The total charges should have been known before we left the ER, as all services and procedures were completed and logged into the system. Yet they only charged us $1472 to get us to sign a Financial Responsibility form that included in the fine print that says we "will pay the account of the patient prior to discharge or make financial arrangements satisfactory to the hospital or any other providers for payment, at the rates and charges that the hospital has on file with the Arizona Department of Health Services." and "It is understood all professional fees are billed separately". So we assumed we had covered the Facility charges before we left.

But this was just a delaying tactic to reduce our resistance to the inevitable. A couple of weeks later a bogus bill with a smaller amount was issued to soften the blow. Calling the accounting agency triggers a response to send us details, which will delay our reactions further. Finally a month after services, the radiology, physician, and enlarged facility bill arrive in the mail. Calling the accounting department again (the only number provided on the bills) on 2/7/2018, gets the next response that they will submit the account for review and that we will receive a response in 30 to 45 days and to not pay any bills until then.

In addition to requesting a review, on 2/8/2018 I spoke with Lola of First Choice Emergency room Patient Relations Team. I was given her number to file a complaint about being told by the ER that it was illegal for them to give us pricing when Arizona state law states the opposite. The first thing she does is give me the number that is on the bill and I tell her that the people at that number gave me her number and she seemed surprised. She diverted several times stating that all the charges could not be known ahead of time and so they would not be able to give me an accurate estimate. I stated more than once, that by going in with a tummy ache that they will automatically issue a CT scan, which sets a level 5 for acuity, that they knew I would be paying over $2541 for a CT scan and $3381 Level 5 care (so my total would be at least $6000) without knowing any additional charges. I told her that afterwards I had looked up other local pricing and Honor Health in Tempe charges $327 for the same 74176 CT scan and they accept immediate care patients. She said that their prices are higher than normal because it is an ER. I told her that if they had given me their prices, as required by law, that I would have sought out more affordable options. Again she diverted with the fact that they could not know all the details of the charges beforehand and thus could not give me an estimate. Several times she mentioned that I had already submitted a review on the charges and that I should wait for that to play out. I asked why then was I given her number to file a complaint about the illegality of their statements on pricing. She finally relented to take some action and said she is going to open a "complaint file" for an investigation which will take a couple weeks to get everything put in the system, reviewed by the facility, reviewed by the FMD, and then coming back to the billing department. That concluded our phone call, but of course I never received a reply back on that.

Of course, no response was forthcoming on the review, but we did start to receive Past Due notices. I called the accounting department again on 4/9/2018 and reporting that we had not heard any response to the previous request for review, we were told that they would submit it for an escalated review. When asking about the past due notices, we were told to pay minimum amounts each month to avoid it going to collections. There was no mention on the bills for a payment plan or what minimum amounts should be submitted, so Felicia gave me amounts of $972.12 for the facility bill and $120 for the doctor bill. I expressed my concern that I might end up just paying these monthly amounts until the bill was paid without ever hearing a response to the review and she assured me that that would not happen.
 
Facility Past Due. 
 
Physicians Past Due. 

I began making monthly payments and waited to hear back on the results of the review. I continued to receive past due bills and no reply to the review. Then in July I received a collection notice (the notice I was promised would not be forthcoming) for the doctors bill followed by a phone call from the collection company where I spoke with Ryan. I informed him that I was still waiting for a response to the review where I felt the Level 5 was incorrect and should reduce the final bill when corrected. Ryan informed my that during his 5 years with the company, he had never seen this facility EVER make any reductions in their billed amounts, that they never reply to reviews, and if I did not pay in full within 90 days, it would go on my credit report. I complained about the practice of the accounting department in misleading me otherwise about reviews and collections, and he stated that he was not part of that process. He argued with me when I called the entire process a racket, but it surely is.
Racket (Merriam-Webster):
3. a : a fraudulent scheme, enterprise, or activity
    b : a usually illegitimate enterprise made workable by bribery or intimidation
    c : an easy and lucrative means of livelihood
 
Physicians Collections. 

Subsequent calls to the Patient Relations Team just gets one to leave a voice mail that is never responded to.

They seem to have crafted the pricing to extract maximum profit. Any higher and it might be more prudent to hire an attorney rather than haggle with unresponsive phone representatives. They probably could have charged me $200,000 for the same services, but I'd completely balk at that and they'd never see a dime.

So as of August I have paid the over priced Physician's bill. I had paid the Radiology bill immediately when they offered to discount it by 30%.

Government lack of scrutiny
I filed a complaint with the Attorney General. I got basically a form letter on 8/3/18 that stated that they will forward my information to the Hospital, that the role of their office is to assist my by initiating communication between me and the party named in the complaint, and that I may wish to pursue this matter through the court system. Apparently the state has no qualms with violations of price disclosures. No wonder this problem will never be resolved! I can hear the laughter from the hospital, when they receive the complaint from the Attorney General. I called the office, which was basically a waste of time, and she said that if their staff wants to pursue it, then it might get addressed, but usually only if there is a pattern and she was not allowed to tell me if there were any other complaints. At least after several pleas as to how I can have someone take an interest in this, she said I could contact the Medical Board, which I have done. A separate email to the Attorney General asking who could tell me if an ER is subject to obeying ARS 36-436.01 went unanswered. My conclusion is that the Attorney General's office does not exist to assist consumers against fraud.
 
Attorney General form letter response. 

On 8/1/2018 we visited Dignity Health. Noel needed to get her medical records to present to another doctor she has scheduled to see to address the 17 mm kidney stone reported to us by Dr. Runyan.

I brought up these issues with the Nursing administrator:
1) The discrepancy in the acuity level between the Nurses Clinical Report,
2) The legality of refusing to disclose pricing at the time prior to service, and

1) She explained that the billing acuity level is based on the number of procedures performed and the nurses is based on the amount of care perceived. What was even more appalling, is that even though both sides use a scale of 1 to 5, she said that the Nurses acuity Level 1 is the most severe, but billing uses a Level 5 to define the most severe; what kind of crazy system is that, if it is even true. She said that she would check into it and get back to me within 2 weeks, no matter what (however this was not true as I never heard back from her and she was not at the facility when I revisited it on 8/14). 2) She said that Emergency Rooms are not subject the the AZ law of disclosing pricing because of EMTALA. She said that since they have to take in anyone regardless of ability to pay, that they are not required to explain pricing as the patient then may not get their required care. However, this applies to nearly all hospitals and there is no exclusion I could see in the labor act that prohibited explaining pricing. So the explanation appears to be bogus.

I called billing again on 8/3 and Teresa (they never divulge last names or employee numbers) said that she would put the account on hold and to not make any more payments until I heard back on a review.

On 8/14 I got the email address for the nursing administrator I had talked to at length on 8/1, who had promised to get back to me within a week, two at the most, no matter what. I sent her a reminder email. On 8/16 I received a reply stating: "Sir, I have forwarded you email to our patient relations. Tonya McActee is the new Facility Administrator for Ahwatukee; and she is aware about your complaints. We will do our hardest to help you. Have a wonderful day!"

About an hour after that email, I received a call from Donna W. of Dignity Health Corporate Customer Service and we spoke for over an hour. The first thing she told me was that there was one big error in that there was no 30% discount that I am entitled to as a private payer. I was a little surprised that someone said I was entitled to pay less than they had been demanding for over 8 months. She was able to look at my records, both for the facility and the physician. When she mentioned that the acuity level was based on the many tests performed and mentioned the EKG, I informed her that it was my opinion that the EKG was only done to jack up the cost and was not needed from the presented conditions. Her response was that the patient has to trust the physician that they are doing what is in their best interest and the patient always has the right of refusal if they don't trust that judgment. She implied that the pain in her neck that prompted the ordering of the EKG could have been due to a cardiac issue, which made me laugh. When I asked her if the ER should have been able to give me any estimate, she said that they only price that they would know is the Level 5 charge of $3,381. I asked if they could tell me that 3381 cost and she said "I believe so". I then told her that the ER had told me that it was illegal for them to give me any costs. She explained that it was my fault because I should go to an ER only when I am in an emergent condition and they can not do anything that would delay or deter your care such as telling patients how much their care is going to cost. Since she could not justify any of this and denied the illegality of it, she stated that we had exhausted this topic. She said that it is not required by law and she would like to see where it says that every single service that's available in an emergency room has to be laid out. She said she can't change the law, she's not the owner of the company, and we just need to move forward and resolve the bill. She also told me that I have to be an active participant and an advocate for myself in determining if there are some things that we want to refuse, which was contradictory to her statement of trust previously. She justified the high cost because we were provided a lot of services.
On 8/20/18 we received a revised bill stating the balance was $4,866.00 after having paid $4,332.00 (which did not match the $1,472 original payment and revised facility $7,726 balance)
On 8/23/18 we received a less formal statement that said our balance was zero, including a $3,060.90 and $732.90 courtesy discounts.

When we got copies of all the records, it includes a Physician Clinical Report where the last page is signed by Dr. Runyan Electronically. If he was physically there and provided service, why couldn't he use a pen? And why was the electronic signature time stamped at 4 hours after we were discharged?
 
Physician Clinical Report. 

She also stated that the physician's bill went to collections because it posted on 6/29 and not by 6/26, even though I mailed it on 6/12 and there is no on-line method of payment available.


Insurance
The health care system in the U.S. has us both coming or going. In checking out the ACA plans available to me in Arizona for 2018 where our income is just above the amount that would grant us any subsidies, the cheapest plan with a deductible below $10,000 would cost us $2,207.92 per month, which would be 51.8% of our 2017 after tax income (not affordable). And with a $8,400 deductible, it would have little impact on my savings from this hospital bill. We will still be paying a penalty of about $1500 on our 2018 tax returns in April 2019 for not being able to afford medical insurance.
 
ACA Plans.