2018 Wrist break (Right radius)

Accident
On 8/17/2018 at 11:10 am, Noel tripped on a crack in the sidewalk in Vancouver BC while on her way to the airport for her return to Phoenix. She went to an ER where x-rays revealed a diagonal break in her right radius. A cast was put on and cut on both sides to allow swelling of the arm. It was recommended that she have surgery no later than two weeks out. She returned home the next day after having to reschedule her flight.

Searching
The search began for a surgeon. I asked several friends and used Google. I first called a couple of businesses that were groups of associates. The first company, after much time on hold, directed me to billing, since I was a new patient. She could not give me any prices until after an evaluation, which would cost $150 to $300. I of course lost the connection when she tried to send me back to appointments. Calling back, I was able to start the process with the appointment scheduler, who told me that the initial evaluation would be $400 and that we should bring the CD of x-rays from the ER visit. The Canadian ER did not proved a CD (even though it was requested by Noel before she left). So x-ray expense would be additional. I thanked her for her time and marched on to the next.

The next firm was similar, a long hold and a need to talk to billing. I was told the evaluation would be $250 to $500 or more. When I said that it sounded like she couldn't really give me a price, she confirmed that. When being transferred to appointments, the connection was lost, and I decided to move on.

The next was an individual that shared an office with one other surgeon that was recommend by a friend that had used him. I could only leave a voice mail and wait for a reply later. She could give me pricing directly of $150 to 200 for the evaluation and $56.25 for each x-ray, but not estimates on anything else. She seemed to lose concentration on our specifics, but I made an appointment for Thursday afternoon.

I was helping my neighbor the next day and he gave a high recommendation for a place he had visited. After reading a few less than stellar reviews on the doctor we had an appointment with, we switched.

Visit
We visited Arizona Center for Hand to Shoulder Surgery where an evaluation appointment was made with Dr. Allen S Liu for 9:15 am on Thursday 8/24/28. Appointments there are $125 plus $35 for x-rays. All payments are made prior to services. After more than half an hour of waiting, we were taken into the back room where a nurse carefully removed the already split cast. Her trepidation at the procedure suggested that this may have been her first time attempting this task. After removal, we were told that Noel would be taken to x-rays next. The nurse had previously taken Noel's blood pressure with a regular personal type of device.
 
Blood Pressure device. 

After about 15 minutes, surprisingly Dr Liu came in and light heartedly commented that this was his fourth broken wrist that morning. The first thing he did was to ask Noel if she had any tingling in her fingers. She replied that normally she doesn't, but the tightness of the cast had given her occasional tingling in the outer two fingers. He commented that since he is already going to be in her wrist, that doing surgery to relieve carpal tunnel syndrome would be good to do. We both looked at each other as she had never complained of any pains similar to CTS. Before we could delve into the subject further with the doctor, he noted that the x-rays had not yet been done and as he left the room, he said he'd return when they were ready. He was only with us for about a minute.

5 minutes later, Noel was take off to radiology. Soon after that, Amber, the physician's assistant came in and said that doctor Liu was busy with another case. She started discussing the break displayed in the x-ray and told us that we would need surgery to have a plate installed (which we already knew). She said she could prescribe Noel more pain medication and that the next step would be to talk to scheduling for the surgery.

Billing
We waited in the internal lobby for another 10 minutes and were called to scheduling. We told her that we were self-pay and asked if there were variations in costs for different surgical facilities. She said she could give me 3 costs, one for the surgeon, one for the facility, and one for that anesthesiologist. She was able to find an opening for the following Monday for the surgery. The physician's bill was easy since it was their doctor Liu and she said he would be charging $2902. The facility charge at Gateway Surgery Center would be $6807 and the General anesthesia would be $448. There was no breakdown as to what was included at the facility, but the scheduler gave them several numbers in order to obtain the quote. All the bills would be need to paid in full prior to the operation and the doctor's fee would need to be paid before noon Friday. Otherwise, the next available surgery date was 7 days later, which seemed very surprising! That was also 3 days outside the 2 week recommended window and another week added to Noel's suffering.

 
Physician bill. 
 
Facility and anesthesia bill. 

I pointed out that it was interesting that there was no Description on the surgeon's bill, but did not get a detailed explanation.

My first chore after returning home was to figure out where I was going to find $10k. I was able to secure extra credit to allow us to go forward, but it was mid-afternoon by then.

I then researched the procedure codes for the physician.
The 25609 is "Under Fracture and/or Dislocation Procedures on the Forearm and Wrist"; thus this was the radius repair.
The 64721 is "Release of the transverse carpal ligament is known as “carpal tunnel release”" (CTR). We had never fully discussed that procedure with the doctor. Upon doing more research, CTR is considered a last resort for the relief of CTS and carries additional risks. Also, studies have shown that the incidence of late carpal tunnel syndrome after volar plating of distal radius fracture is similar to general population Since Noel was asymptomatic, it seemed that this procedure was not necessary. I would have to wait until the next day to request to have the CTR portion cancelled. The adding of the CTR perturbed me as it seemed the surgeon was padding his income and putting Noel into a longer recovery process with more pain as well. Reviewing the facility itself, I discovered many negative reviews, where their predatory billing practices were exposed.

I did more research and ran across another doctor on Yelp that was independent and appreciated by many of his clients. The front desk answered very quickly, answered my questions as best as possible, and was very attentive and friendly. The office visit was a flat $175 which included any needed x-rays. They normally see first time patients on Tuesday's and Thursdays, but said if we came in that afternoon, Friday, we could probably get squeezed in. We showed up for our 3:15 appointment and everything went smoothly. The staff treated us well and the doctor saw us promptly. He was not rushed, went over several options for the surgery, and said that the CTR operation would normally be done at a later time if needed. He actually gave us care, letting her know to ice it, keep it elevated, what foods to avoid prior to surgery, etc. He explained the new bruise above the elbow was from blood pooling from not keeping the wrist elevated (not a deep tissue bruise as the PA at the other facility had said). He said it was best to have the swelling dissipate more before doing the surgery, so we were not yet running late. His billing can be made in monthly payments after the surgery, if need be. So, he pretty much said all the right things and we were happy we that we had kept searching. His wife is the scheduling manager and she was very helpful, knowledgeable, and friendly. Surgery was scheduled for 8/30/2018 the following week.

 
Top. 
 
Side. 
 
Oblique. 

Surgery was performed at 10:45 am on Thursday 8/30/18. The staff were very friendly and appeared competent. The doctor said everything went well and that she should try to use the hand as much as possible right away. She had some clear mesh over the incision, rather than stitches. We were home by 2 pm. A follow up appointment is for 1 pm on 9/7. The wrist and arm were in extreme pain for the first week. Swelling subisided quite a bit over the first few days, but was still evident after a week.

 
Top. 
 
Side. 
 
Oblique. 
 
Patch. 

The physician's bill was only $1000 instead of the previous $2920, but the anesthesiologist jumped from $448 to $1100 and the facility bill jumped from $5807 to $8357, so we were out of pocket by quite a bit more. However, Noel could not wait any longer to get the surgery completed.

So the little trip on the sidewalk set us back over $12k
$824 Vancouver ER
$560 Vancouver 3 X-rays
$173 Flight change
$160 First evaluation
$175 Second evaluation
$1000 Surgeon's bill
$1100 Anesthesiologist
$43 Anesthesiologist X-rays of chest
$8357 Surgical Center
$31 Pain pills
$15 Wrist brace
$10 Reusable Ice Pack
$12,448 Total


A month later we received a surprise balance bill from the facility on 9/29. It stated that we owed an additional $15,177.02 out of a $39,244.43 total with a 40% discount of $15,689.70.

Fortunately I record my phone calls (legal in AZ) where I was told:
"We just go by the medicare allowable for the cash pays. We discount the OR time and so we don't charge you for the OR time or any supplies. We just charge you for the actual procedure that's being done."
I was told in that call that my cost would be $8357.64, which I considered a verbal contract for the facility charge. After a depressing weekend of anticipating months of wrangling with various billing agents and eventually having to pay thousands more, I was surprised after my phone call on Monday morning to be told that the statement should not have been sent to me and I now had a zero balance.