Wednesday, September 3, 2014

Health Care and the $20,000 Bruise: A different take

Twitter is buzzing about yet another medical billing horror story. This one appeared in the Wall Street Journal and was written by Eric Michael David who is an MD PhD JD and an officer at a biotech company.

He saw a large, swollen bruise on his three-year-old son's head several days after falling off his scooter. Other than the bruise, no other abnormalities were mentioned. He took the boy to "one of the top pediatric emergency rooms in the country" to have a CT scan done. It showed "a small, 11-day-old bleed inside his head, which was healing, and insignificant."

Dr. David received a bill for $20,000, $17,000 of which had been paid by his insurance company. He was responsible for the remaining $3000.

He noted a $10,000 charge for a trauma team activation which he said never happened. After a lengthy series of exchanges with the hospital's billing department and Dr. David having to prove that a trauma team activation was unwarranted and not permitted by certain regulations, he was able to have the charge rescinded.

The essay went on for some 1200 words listing the steps that he went through. He correctly described what a mess American healthcare delivery is and why as long as overuse and upcoding are rewarded, the Affordable Care Act will not fix it.

Dr. David was right to contest the $10,000 charge for a trauma team activation that wasn't indicated and didn't even occur.

What he didn't address was this.

Why would a doctor who said that he had "served on trauma teams in two of the busiest hospitals in New York City" feel the need to take his apparently asymptomatic son with an 11-day-old injury to an emergency room for a CT scan?

Doesn't this imply overuse of a different type?

Secondary questions:

Did anyone bring up the issue of radiation from the CT scan?
Did the docs in the ED think a CT scan was necessary?
"Inside his head" is a rather odd phrase. Does it mean intracranial? Intracerebral?
Was "one of the top pediatric emergency rooms in the country" the only option or could this asymptomatic boy have been seen in a doctor's office?
Why is the charge for a trauma team activation $10,000?


artiger said...

I'm not going to try to defend our dysfunctional health care system, but when I finished the second paragraph, I too wondered why he didn't know better than to go to an ER. I guess well-educated isn't the same thing as intelligent. But a $20,000 bill sells more stories.

He might ought to consider himself lucky for not being reported for suspicion of child abuse/neglect. I wonder if he would have been if he didn't have three doctorates.

Pamela Curtis said...

Thank you for raising these points. I was equally skeptical as to why an "11-day-old bleed" required and ER visit!! He already waited 11 days, why not wait one more and see your Pediatrician???

Anonymous said...

Has anyone asked why the 3yo son of a doctor and lawyer and executive (seriously?! :) ) was not wearing a helmet. At least he admitted it at the end, though did not address why he went to ER in the first place.

RobertL39 said...

Health care costs need to be reduced...
for everyone but me.
With his superior knowledge and experience, he obviously felt entitled to rush in for a CT scan 11 days after the injury.
Your questions are right on the money (sorry for the double-entendre) and deserve a wider audience.
Where was the child's pediatrician (not being a subscriber, I can't read the whole article, so feel free to delete this question if he answered it in the article)?
"More care isn't usually better care. Quite the opposite, in fact."

R said...

If you want to circumvent the WSJ paywall and actually read the article you can do so by Googling the article's title "
Health Care and the $20,000 Bruise".

JEN said...

No symptoms = watch and wait in this case. Was a neuro exam normal?

Skeptical Scalpel said...

Artiger, Pam, and Anon-- I agree. Why not just go to the pediatrician?

Robert, he never mentioned a pediatrician, and Jen, there was no mention of any symptoms or neuro exam.

R, you are correct. If you google the title of the article, the first hit is the full text version.

webhillizzy said...

The hospital fraudulently billed my insurance company for IV fluids, anesthesia consult, epidural anesthesia, and a few other things, on the bill for services provided during my second labor & delivery. When I called the hospital & asked about it (because I had no IV, no epidural, in fact saw an OB for 5 minutes at triage and then no other physician until about 15 minutes after my daughter was born) they said they were "unable" to change the bill unless I sued them. This was a large teaching hospital on the east coast. Then I called the insurance company and explained they'd been hugely overbilled & they said it didn't matter, it all evens out eventually, sometimes hospitals underbill. I am still irritated by this.

Skeptical Scalpel said...

Webhillizzy, the more I read about hospital billing, the more confused I get. I guess it's like malpractice suits. The lawyers for both sides get rich. Hospitals and insurance companies are raking it in. Who cares if there are overcharges?

Anonymous said...

Really, when this kid is dying of brain cancer at 40 will he be able to sue Daddy-o for the ridiculously bad helicopter-parent decision-making that led him to that fate?

Anonymous said...

MD, JD, PhD skipped common sense 101?

Anonymous said...

And.... why did his dopey inurance plan pay for the non-emergency?

KAC RN said...

A helicopter parent would have had him in that ER before his head hit the concrete or would have been circling and never allowed the fall, in the first place. Insisting on a bright shiny top of the line ER sounds more like an entitled guy who probably carries copies of his doctorates in his breast pocket than someone really concerned about his child. It took 11 days to notice his kid's head was bruised and swollen? Must have been away on business. More money than sense. Maybe he needs a Nanny...

Skeptical Scalpel said...

I'm not sure about the brain cancer. If you have your first CT at age 3, You may be on your way to many more.

Common sense is a theme. I agree.

I wondered why the insurance company paid too. The author did say that they didn't want to fight about the trauma team so maybe they just couldn't be bothered to question the whole bill either.

Anonymous said...

You had me at "falling off his scooter"!! Why on earth does a 3 yr old even have such a thing??

No scooter
= no need for a helmet (that he did not wear) and no bump to the head
= no trip to the ED, no (likely) unnecessary CT and no erroneous trauma team charge

The displayed lack of common sense is indeed a theme.

GeronimoMD said...


I think it is safe to assume that this type of financial mess with inaccurate/fraudulent billing is commonplace. The Time magazine article on the paymaster detailed the extent of the problem nicely. Considering this fact, and your previous post regarding the increasing employment of surgeons, and indeed all physicians, I think it is also safe to assume that a growing number of doctors will be a party to such billing practices even if only indirectly.

I don't think that any conscientious doctor feels good about this prospect. So why rollover and take it? Dr. Ruggieri proposes unionization. I'm not sure striking doctors are ever going to go down well or garner sympathy from any quarter. Instead, we need to politically organize if there is any hope of stopping this trend of the ethical imperatives of medical practice being co-opted by hospitals' and insurance companies' financial bottom line.

A hospital without doctors is not a hospital. A health insurance company insures nothing without doctors to provide the healthcare. How did we convince ourselves we have no power in this situation?

If our professional societies fail to make it happen, they should be thrown out or replaced and the interests of practicing clinicians given a true voice.

Anonymous said...

I've got a head that if I ever lost all my hair would look like I lost the war, as a child I spent many a ruff and tumble with an ice bag as the consolation prize. Trips to the ER anymore are to common, and in this case laughably so!

Dr. L F S said...

I'm curious as to why he did not requisition the MRI, himself, as long as his medical license remains active!?

Skeptical Scalpel said...

Docs have been talking about forming a union for years. I doubt it will ever happen.

It wasn't an MRI. It was a CT scan. I'm not sure he has an active license. And if he ordered it himself, what was he going to do with the information?

Anonymous said...

"Why is the charge for a trauma team activation $10,000?"

I *love* this one. Hospitals use 'chargemasters' for their accounting. They have no outside accountability to anyone, any institution--no oversight at all for what they charge. What the chargemaster says, goes. Unless you're in Maryland, and only in Maryland are your hospitals' charge masters regulated. Are they regulated properly? That's an entirely different question. In California, they aren't regulated like they are in Maryland, but they are submitted to the state, which then posts them online so that people can comparison shop if so inclined.

I became acquainted with the subject after a c-section, and 5-day hospital stay with my newborn. My bills were numerous, and rather silly. Some of them were freakishly huge and totally ridiculous, and I was able to work them down over a period of months. It was not the best experience, and I completely feel for people who can't handle either medical or accounting terminology. But yeah, Google is definitely your friend when trying to figure out the codes, and why you were charged $567 for item B on day 2, but only $254 for the same item on day 4.

Skeptical Scalpel said...

Regulation might not be necessary if patient knew what the charges were up front. People could shop around somewhat. Of course, you wouldn't be able to choose your hospital in an emergency so maybe regulation is the answer.

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