Copyright 2012 Isaac M Stone

One man's journey through the labyrinth of medical billing

This is a true story

The names have been changed or redacted

and other obfuscations have been used

to confuse the lawyers


A Visit to the Local ER

Ira is a 64 year old male in good health. He's never smoked and maintains his normal high school weight. He has no medical problems and takes no medicines. His only past medical history is a kidney stone 30 years ago. That stone passed on its own without problem.

At 9 a.m. on December 10, Ira was awakened by severe abdominal pain. It started in his right flank and radiated to his right groin. When he started vomiting, his wife took him to a local ER.

Over several hours he was seen by multiple providers. These included nurses, a physician's assistant (PA), a general surgeon, a urologist, and a hospitalist. Blood, urine, and CAT scan testing were done. By 2:30 p.m. the diagnosis was clear - Acute Ureteral Colic (recurrent kidney stone). He was then transferred to the CDU (Clinical Decision Unit). Some time during all this he spontaneously passed the stone.

The Standard of Care for kidney stones is straight forward:

    • Relieve the severe pain

    • Stop the vomiting

    • Strain all urine to catch the stone for analysis

    • Culture the urine to be sure there is no infection as well

    • Admit for possible surgery if the stone is not passing

FOUR of these critical steps were neglected. Thus, his care did not meet the Standard per an expert in the field. Ira was in the facility a total of 24 hours. He did not have surgery. He did not require admission. Yet, the hospital and its providers later presented bills totaling about $16,000.

Ira feels that these charges are arbitrary and excessive. This is the equivalent of 130% of his annual social security income, a year's college tuition, a new car.

This is Ira's story

The Event

A Walk-Through of the Patient's Encounter with the ER


A Review of the Results by an ER Physician

Hospital Bills

A Detailed Description of the Charges and Services Provided

Doctors' Bills

All of the Doctors Billed Separately - Sort of a la carte

Communication with hospital

Who Speaks for the Hospital ?

Price Transparency

What You Don't See is What You Get

The Promise and the Reality of Fair and Open Pricing


"Show Me the Money"

Patient Bill of Rights

The People Who Dealt with Ira Had No Idea



This hospital does a lot of advertising about quality of service. Its image is always clean and polished. But never do they mention that if one avails oneself of these services, one may very well be bankrupted by the bills. The shock, the intimidation, the overwhelming sense of being chased by a juggernaut can cause more damage to one's health than the reason for the visit. "First, do no harm." apparently, does not apply to bill collection.

During both the visit and the following Communication with hospital , Ira felt as if he was dealing with a basketball team without a coach. Ira was the ball. He was constantly being handed off to the next player with little or no oversight or plan. Nurse to PA to surgeon to urologist to CT scan technician to waiting room to second bed to hospitalist to extended stay room to other nurse to other hospitalist. An assembly line of talent. There was no discussion of diagnosis or treatment with the patient. No one was in charge of the case. There were similar handoffs in the billing. No single individual with which to discuss issues. Billing to customer service to various physicians for questions to financial counselor to auditor back to customer service to medical records to billing. Distributed deniability. No followup.

The client has a right to expect that charges for service are fair and reasonable. What rational human being can look at these prices and call them fair or reasonable? The Flomax charge was 10 times its cost. The CT scan charge was 100 times the cost.

How valuable is a CT scan and radiologist report that mentions neither the appendix nor the ureters? Both of which are important for a diagnosis.

If an ER physician is not "hands on" for a Level V emergency, then when is he needed?

Premium price. Premium service?

The Florida Agency for Health Care Administration, which licenses hospitals, advised that there is no patient advocate in the state government to intercede for people who feel that they have been overcharged or that the bills are excessive. There are no pricing controls on hospitals. They are free to charge anything for any service they provide. Most hospitals have case workers that can review bills and negotiate settlements, but there are no rules requiring them. The charges are considered valid by default. When a hospital does not have a case worker or an arbitration policy, what remains? It is left to each victim to fight his own battle against a powerful and experienced foe; to use whatever legal means are available. Until the politicians get the message that this problem must be fixed or a legal class action is brought and won or enough people do what Ira did, we will have a hospital system whose pricing policy lacks transparency, competition and government oversight.

The Event

It is mid morning on 12/8/10 and Ira, a retired local resident, is wheeled into the emergency room at a nearby hospital. He is experiencing severe abdominal pain and is vomiting. After about 15 or 20 minutes, when a bed is available, he is moved into an examination room. He is given an IV, pain meds and something for nausea. A history is taken and an abdominal exam is done by a nurse practitioner. Apparently, no ER doctor was available. A surgeon and a urologist are called and each ask routine questions and perform abdominal exams. The surgeon does not believe the problem is an appendicitis. The urologist does not believe that the problem is a kidney stone.

A CT scan is ordered and Ira is wheeled to the scanning room. A scan is done, a dye is injected and another scan is done without leaving the machine. The process takes about 10 minutes. Ira is then helped back into the wheelchair and moved by the technician to an area just outside the scanning room. Ira begins to vomit and asks to be moved back to the bed. But the exam room had already been given to someone else. Instead he is wheeled to another crowded waiting room in pain. Ira pleads with the person that moved him here to take him back to the bed. She then does find another room and he is allowed to lay down.

Ira remains in this room for most of the afternoon. A hospitalist determines that he should be held overnight. He is wheeled to an extended stay facility to be watched The Urologist visits Ira in this room to discuss the results of the CT scan. He says there is a kidney stone but that he could not see the ureters because the dye hadn't made its way there by the second scan. He suggests a third scan. Since Ira had already had two scans, each the equivalent of 400 chest x-rays, he declined. The surgeon later visits and is convinced that surgery is not indicated.

By early morning, Ira is feeling better and ready to leave, but must wait a couple of hours for a very busy hospitalist to see him and write a prescription.

Except for the person that moved him from the scanning room to the waiting room, Ira feels that all of the personnel involved in the case were well intentioned and seemed to care. But he was a third party to the treatment, an object to be dealt with. At no time was he consulted about what tests should be done or what possible conditions or treatments were being considered. The order was given and the care givers moved on. And the department seemed over committed, understaffed, and under managed. There was no apparent follow, either human or electronic to know where he was from time to time or place to place. At one point, one of the a nurses that had seen him earlier, opened the door of the second room and asked him why he had been moved.

His case was declared a level V emergency, yet he never saw an ER doctor and was not diagnosed. If a ER doctor is not 'hands on' on a level V, then when is he needed?



  • 36 year career Emergency Medicine physician

  • 4 X board certified in Emergency Medicine and currently certified thru 2017

  • has taught E.M. and ACLS classes at various institutions

  • recently published a medical textbook


    • To begin with, the patient is a 64 year old

a) white

b) male, without significant past history ( diabetes, hypertension, cancer, etc.), has

c) sudden

d) severe

e) ONE sided

f) abdominal pain

g) in the morning.

    • ALL of these are clues to kidney stone or aortic dissecting aneurysm. Patient needs immediate pain relief and STAT workup to figure out which one. Kidney stone usually gets admitted for analgesia and only has surgery if can't pass stone in day or so.

    • Aneurysmal dissection needs immediate surgery or will die.

    • Morphine 4mg-way too small dose for this kind of pain unless BP was low from shock ( it never was ).

    • Flomax-primarily a prostate out patient drug which maybe could relax ureter muscles and help pee out a stone but very unlikely.

    • Toradol-this is like giving Motrin IV and VERY effective for kidney stones.

    • Ondansetron-very expensive anti-nausea/vomiting drug. Some N & V drug needed since usually the patient will vomit from a kidney stone AND Morphine's #1 side effect is N & V.

    • Cheaper/older N & V drugs like Phenergan are

a) generic

b) sedating which is good when you're in pain, and

c) help stop the vomiting and prevent nausea from morphine.

    • CBC: this test has neither the sensitivity nor the specificity to diagnose nor change patient management, but is "routine". However, ordering a 2nd CBC, and WITH differential was of NO value.

    • Urinalysis-every kidney stone gets a UA to look for blood (stone) or white cells/bacteria (infection), A bedside dipstick tells the same thing much faster but the urinalysis can't be avoided and probably a urine culture as well.

    • Rectal exam for occult blood cost $72 to do in the lab instead of at bedside but may be the new government regulation depending on your date of service.

    • PBM (Basic Metabolic Panel) checks for diabetes/ electrolytes/ dehydration/kidney function/ and would always be done-but I can't justify 2 being done.

    • CT scan-the CT scan of choice is the CT pyelogram which will show EITHER a stone or an aneurysm with only one CT-not 2.

    • If TWO separate CT's were done ( abdomen & pelvis ), this exposed the body to double the radiation ( usually about 500 chest x-rays worth per CT of the abdomen ).

    • ER doctors' charges vary by patient complexity. Level I is the least complex. Level V is most complex workup. Ira was charged a Level V - even though no ER physician ever saw him at all !


The following are Ira's medical records. The reviewing physician's questions, observations, and anomalies are highlighted in red. Names have been removed.

Hospital Bills

Usual, Customary, and Reasonable ?


Charge without Challenge ?

The following is what Ira received when he requested an itemized bill from the hospital, with a disclaimer in red:

After much ado (see: Communication with hospital ), the following CPT based statement was made available:

So how are these prices determined? Is there a rationale to the setting of prices? Is it, in any way, based on cost of service? Are they reasonable?

{ More than two years ago, the Medicare Payment Advisory Commission reported that hospitals often charge much more than their cost for certain services. The Centers for Medicare and Medicaid Services (CMS) confirmed these findings, and last year shifted to cost-based diagnosis-related group (DRG) weights from charge-based DRG weights.

Given the facts that this shift constitutes one of Medicare's most significant changes in 25 years, and that there is an increasing emphasis on healthcare price transparency in this country, it is important to dispel some myths about Medicare that have contributed to hospitals' confusion regarding charging, particularly for goods and services provided in ancillary departments.

see: }

{ PRM Section 2204, Medicare Charges, which states, in part, that the ˜Medicare charge for a specific service must be the same as the charge made to non-Medicare patients. It needs to be read in the light of section 2203 which makes clear that consistent charging is required for a proper determination of Medicare cost-based payment but that Medicare can't mandate consistent charging. If a provider has a different charge structure for certain services provided in the inpatient setting than in the outpatient setting or for different classes of patients, e.g., Medicare patients v. other classes of patients, Medicare expects the provider to adjust the charges for Medicare reporting purposes to reflect the same consistent charge for all patients in all settings. The adjustments are often referred to as 'grossing-up' the charges, i.e., raising/adjusting certain charges to reflect a consistent charge level for Medicare purposes.

see: }

CT Scans

CT SCAN $3187

Computed tomography, pelvis with contrast materials (CPT code 72193)

CT SCAN $3373

Computed tomography, abdomen with contrast materials (CPT code 74160)

Radiologist report:

TECHNIQUE: Contiguous axial images were obtained from the lung bases through the pelvis following the intravenous administration of 100ml of Optiray 300.

Appendix not seen. Ureters not seen.

This is considered by the hospital to be 2 chargeable scans even though there was only one radiologist report. One might ask: How much does each scan cost the hospital? Using anecdotal evidence readily available on the Internet, one can 'ballpark' the direct cost of the equipment to between $20 and $30. These charges, then, are over 100 times that cost. There are hospitals that report total cost for a CT scan (equipment, maintenance, personnel, etc.) to be as much as $600. But how much did the second scan cost? ZERO. To break the procedures into two gives the hospital the excuse to charge again. This yields over $3,000 of PURE profit.

At $6560 per 20 minute scan, the hourly rate is $19,680; at 30 scans per day, the daily charges would be $196,800;

or $71,832,000 a year - a pretty good profit for equipment that costs about $1,000,000 and lasts at least 5 years.

Medicare has recognized this convenience and has decided to pay only once for these tests, to wit:

{ Center for Medicare Services (CMS) assigns: CPT 74176 to APC 332 (CT without contrast) paid at $193.85; CPT 74177 to APC 283 (CT with contrast) paid at $299.81 and CPT 74178 to APC 333 (CT without contrast followed by contrast) paid at $334.24.

These are the same APCs into which the CPT codes for a patient encounter involving only a single CT scan of either the pelvis or the abdomen are placed in 2011. Thus, these combined services are being paid at the rate of a single service for 2011.

By contrast, under the current CY 2010 payment policy (but using 2011 rates), if a patient receives an abdominal and pelvic CT scans in a single hospital outpatient department encounter, the hospital bills two separate CPT codes that will be paid under a composite APC, either composite APC 8005 (CT and CTA without contrast) paid at $420.85 or APC 8006 (CT and CTA with contrast) paid at $628.61. }

{ see: }

Level V Emergency - Hospital


CPT code 99285. This is a general not well defined charge by the hospital for the handling of patients. It varies by complexity of treatment. CPT 99281 ( straightforward medical decision making ) to CPT 99285 ( medical decision making of high complexity ). Theoretically, the more dire the condition, the more service is required. It does NOT include IVP services, which are billed separately. It does NOT include ER doctor services, which are billed separately. It does NOT include laboratory services, which are billed separately. It does NOT include radiology services, which are billed separately. It does NOT include hospitalist charges, which are billed separately. It does NOT include specialty doctor services (urologist, surgeon), which are billed separately. It does NOT include observation services, which are billed separately.

A hospital, less than 10 miles away, charges about $1100.

Medicare pays $329.73 for this service.

{ see: }

I V Push

IVP 96374 $143

IVP 96375 $143

IVP 96376 $143

These three codes are used to identify a 30 second to 2 minute procedure that moves a liquid drug from its container into a syringe and then into the IV tube that is constantly infusing IV fluids ( e.g. saline ) into the patient.

This routine procedure is usually done by a nurse or CNA. It does NOT include the actual drug, which is billed separately. If one assumes 2 minutes per IVP, then the charge for this service is $4,290 per hour. There were 7 such charges amounting to $1,001.

Medicare pays $37.44 for this procedure.

{ see: }



CPT code G0378. This is a general term for nursing charges to watch the patient for any adverse changes in condition. It is an hourly bed and services charge combined. Blood pressure, temperature, pulseox readings are taken periodically. There were 3 such charges while still in the emergency department and 15 in another department. Total for these charges were $2,358.

Assuming $30/hr ( the high end of the range ) for a Florida Registered Nurse, one could obtain 24 hours of full time, one on one care for $720.

Medicare would pay a total of $705.27 for this charge and Level V emergency CPT 99285 combined.

{ APC 8003”Level II Extended Assessment and Management Composite

This APC requires a level 99284 or 99285 Type A ED visit, a G0384 level 5 Type B ED visit, or 99291 critical care to be reported on the day of or day before observation. In addition at least 8 units of G0378 (Observation services, per hour) must be reported and no procedure with a status indicator of T (significant procedure subject to multiple procedure discounting).

These composite APCs are reimbursed in a single payment for the combination of an ED or clinic visit with observation instead of a separate payment for both the observation and the ED or clinic visit. APC 8002 payment is $381.34 and APC 8003 payment is $705.27. }

{ see: }

Contrast dye


CPT code Q9967. Separate charge for dye used in CT scan NOT included in CT charge.

Miscellaneous Drugs

CIPROFLOXACIN 400mg IV J0744 $163.20 ( about $12 at retail )

TAMSULOSIN (FLOMAX) .4 mg pill $9.24 ( about $1 at retail )

ONDANSETRON IV J2405 $132.14 ( about $12 at retail )

Medical Records


One more little hurdle. One dollar per printed page plus postage. The information is kept electronically. So, it could be sent over the Internet for no cost. But the state of Florida allows this charge, so the hospital indulges and will not use electronic delivery methods.

Level V Emergency - Physicians


This was for a Level V emergency (CPT code 99285). A 64 year old man with severe abdominal pain, sweating, and vomiting could easily have aneurysm or multiple other life-threatening conditions. Therefore his workup and care was declared an ER physician Level V for billing purposes. Even though Ira was never seen by an ER physician. A Physician's Assistant ( PA ) handled the case.

{ CPT is the most widely accepted coding reference and has been used since 1966. Claims submitted to MCOs and States include the emergency levels of screening and treatment. They range from CPT 99281 ( straightforward medical decision making ) to CPT 99285 ( medical decision making of high complexity ). These codes reflect not only the complexity of the treatment but also the time and difficulty of making a diagnosis. The AMA publishes guides that specifically describe the categorization of levels of emergency and give examples.

see: }

According the American College of Emergency Physicians a Level V (CPT code 99285) requires

    • medical decision making of high complexity leading to an ED physician diagnosis

    • complexity of treatment

    • complex discharge instructions

{ see: for case examples and definitions of discharge instructions }

In this case, there was no

    • diagnosis

    • complex treatment

    • complex discharge instructions

The discharge instructions were left to the hospitalist, who had not seen Ira until just before discharge.

{ see discharge instructions in Analysis }

Could this be a case of 'up-coding' ? And how does this affect the hospital bill? The hospital uses this number to charge for its services.

See the following links for details concerning proper assignment of CPT codes:

American Academy of Emergency Medicine - AAEM CPT code 99285 Medical decision of high complexity

ED Facility Level Coding Guidelines CPT code 99285

Emergency Medicine | Correctly Apply 99285 Acuity Caveat to Optimize E/M Coding


In case surgery might be needed, a consult was requested by the PA. The surgeon visited twice, charging: $237 for CPT code 99222 and $127 for CPT code 99232.


Consult CPT code 99252.


Because Ira stayed over a midnight, the hospitalist group felt justified in charging twice for their services: $300 for CPT code 99220 and $135 for CPT code 99217.


Apparently, $6560 wasn't enough to compensate the radiology group for a CT scan. The only charge not an even dollar figure, could this be because of a rupee to dollar conversion?

Communication with the hospital

Email to hospital 2/17/11

I am in receipt of an itemized list of charges for service date 12/8/10.

I would like a description of reference numbers and insurance categories for that list.

The EOB from my insurance company shows groups that don't seem to reflect your categories. Was the bill, that was sent to the insurance company, identical to this list?


Ira Man


Insurance companies can take our claim and input it anyway they wish into their computer system and break the charges down to how they want them listed. Insurance companies are billed using the standard UB04 billing form which does list CPT and revenue coding that is required by insurance companies. This coding is not available in a form that the hospital can send to you. If you wish a copy of the UB94 billing form, you would need to complete a HIPAA form and return it to the hospital first. Reviewing the charges listed on the UB04 is still not going to help you understand how your insurance company processed your claim.

The best thing for you to do is contact _____ and discuss directly with them how they processed your claim. The hospital billed _____ for the total charges of $13,856.95. We applied a discount to those charges of $7,690.61 per our contract with _____ bringing the allowable amount due on your claim to $6,166.34. _____ did not pay anything on the charges and advised they were applying the entire allowable amount to the deductible you have as part of your coverage with them. They assigned a patient responsibility of $6,166.34. You made a deposit payment of $150.000 at time of service and this leaves a balance due of $6,016.34.

Your two big charges were for the two different CAT Scans you had of your abdomen and pelvis. Other charges were the Level 5 care charge and various bloodwork, urine culture and medications ordering by the treating physician.

Thank You,

Customer Service

Email to hospital 2/21/11

I would like to know what the reference numbers down the left side of the detailed list mean, as well as the insurance category numbers.

While the description of service might be very informative to a medical professional, they mean about as much to me as a receipt from a grocery store with only numbers on it.

For example: 6020004032 762 OBSERVATION EACH HOUR

What service is being performed 18 times at a cost of $131 each time? And are they billed differently if done in the ER vs. the nursing units?

7180004160 352 CT ABD WITH CONTRAST

7180002193 350 CT PELVIS WITH

I was on the machine one time for less than 10 minutes and received one report from the radiologist. The next day, the urologist wanted another CT SCAN because the ureters were not visible and he could not understand why. So I would like to know the precise description for each of those reference numbers and why there were two charges. I want contact information for the radiologist so that I can further understand the situation.

In light of the current push to make medical billing transparent, it seems to me unreasonable that one would have to jump through hoops to obtain these descriptions. I assume that these numbers are industry standard and are therefore not secret. Are they not online?

In any case, I will do whatever I have to to obtain full disclosure.


Ira Man


The item number listed on left side of the itemized charges is only for _____ hospital reference and is not included in any billing form to an insurance company. It is used in-house only to help determine different revenue departments of the hospital where the charges apply.

I have sent your account to our auditing department to review the Level 5 charge to determine if it is correctly posted per your presenting condition. I have also asked them to review the medical records regarding the 18 hours of observation listed as part of your charges to determine if that is correctly charged. The audit can take up to 7-10 days and you will receive a letter in the mail with the outcome.

The treating emergency room physician ordered observation during your emergency room visit. Those charges could have been for use of equipment used by the staff as part of your observation, cost of hospital staff to monitor and complete your observation. You may want to contact the treating physician to discuss why he ordered the testing that was done and the medications ordered. You can also order your medical records if you wish to review them. _____ medical records phone number is _____.

The two different CT scans would have been done in one setting. Again the physician ordered a CT scan of your abdomen and another CT of your pelvis. The cost is not determined by the length of time for the test but by the type of procedure ordered and type of equipment needed for staff to perform the testing.

The radiology services were provided by _____ Radiology Specialists and their phone is _____. I do not know if they have any e-mail address or not.

You may want to make an appointment with a financial counselor at _____ hospital to discuss your situation. You may want to contact _____ to set up an appointment.

Thank You,

Customer Service

Phone calls to hospital

Ira left 2 messages at the number for the financial counselor.

On 3/7/11 an associate of the financial counselor called and spoke to Ira. He explained the situation to her. He said that the review was taking much longer than he had originally thought and he offered to pay the hospital $100 a month or 10% of his social security income while the review was ongoing. She said that that amount was inadequate. She said that she was just filling in for the counselor, but the charges are the charges. Tests were ordered by Ira's doctor and the hospital complied. Essentially she said there is nothing really to discuss but that she would call back next week to follow up.

In other words, the actions of the ER doctors hired by the hospital to work in the ER were not the responsibility of the hospital. Ira inferred an attitude of righteousness and infallibility.

Email to hospital 3/9/11

In response to your emails of 2/17/11 and 2/22/11, I am hereby respectfully requesting the following:

o The opportunity to dispute the invoice sent by _____ hospital, an explanation of your mediation and arbitration policy, my rights under the law and how I can participate.

o A single point of contact with the hospital, such as a case worker or patient advocate.

o A copy of the UB94 billing form which includes CPT and revenue coding, as previously offered, and whatever HIPAA form is required to obtain this.

o The automated harassing phone calls to stop.

The phone number for _____ medical records _____ that you gave me was answered by a fax. Is there a better number?

Thank you.


Ira Man


I put in the postal mail to you a HIPAA form for you to complete and return to the hospital. Once that is on file with your account a UB04 standard billing form can be sent to you.

I have placed a no-call flag on this account.

I apologize that the fax number was given to you for _____ medical records. Their phone number is _____.

Your account is noted that R C from our Auditing Department is going to contact you.

Thank You,

Customer Service

Email to hospital 3/17/11

You should have received the 2 page HIPAA form by now. Is there some further action that I should take to obtain the UB04 billing form?

I placed a call to _____ medical records at that number. The phone was answered "Health Information Management". I assume it was the correct department.

The woman who answered, first said that I had to appear in person with photo ID to obtain the information. When pressed, she allowed that a 3 page HIPAA form could be mailed in with the caveat that one must agree to a $1.00 per page fee to be paid to an affiliate group for copying these records. No information could be provided as to the extent of the pages other than it depended on the length of stay, etc. When pressed further, she indicated that either the information or the form was available online, but she could provide no further information.

Can you?

I thought that HIPAA was to prevent others from seeing my information, not to inhibit my access.

Can you explain?



Ira Man


Your HIPAA form was worked yesterday and a copy of the standard UB04 billing form was put in the postal mail to you. Please keep in mind that the HIPAA for completed only asking for the UB04 billing form and nothing else.

You could certainly understand why the hospital would not mail out medical records by someone just calling up and asking for them. You can either go in person to _____ hospital to the medical records department and request them with proper ID. I put another copy of the HIPAA form in the mail to you that you can complete and return to the Medical Records Department that does state you want your medical records for this date of service. You can take that form and go in person to get them or you can return in the mail. If you return in the mail or by FAX, they will then advise you the cost of getting the medical records per page before the records would be copied and given to you.

Medical record can be just a few pages to hundreds of pages. It depends upon length of time, orders from the treating physician, how many procedures, tests ordered and discharge information as to the length of the medical records.

Thank You,

Customer Service

Visit to hospital Medical Records Department 4/1/11

Not interested in extending an open order to the records department, Ira decided to look at the records first to determine which might be of value to him. So he went to the hospital, asked the friendly concierge (no kidding) where the medical records department was, found it and asked to see his records. With a smile, a very pleasant woman offered a form to fill out to request them. When he explained to the woman that he wanted to see first what he was purchasing, he was told that he had to go to the central records area (in another hospital in the chain, about 70 miles round trip from here) to sit down with someone and review them. Ira asked where the records were. She told him that they were electronic. He asked why he couldn't then view them online and was told that because of HIPPA they had to be kept secure and this required face to face meeting. He asked why this meeting could not be done here. She told him that there wasn't enough room in this hospital to have such a meeting, they only had small cubicles. (honestly, no kidding) He was offered a business card with a name of a supervisor and a phone number of someone who could answer his questions further. With a smile, she bid him good day.

Laugh or cry? Ira decided on the former.

Phone call to Manager Release of Information 4/1/11

A very friendly, knowledgeable and helpful woman took his call and explained that these meetings, which cost $50 per hour, were intended to be for the more complex hospitals stays that involved combing through hundreds of pages of documents pertaining to stays that were long term and possibly involving lawsuits. She reviewed his simple stay and suggested the few items that might be of value. She agreed to email him this info and offered her direct number for future requests.

A diamond in the ruff.

Her email response

Per our conversation today you have already received your labs & radiology from your visit at _____ on 12/8/10 and you are interested in receiving your emergency physician sheet, history & physician report & your consult report. These 3 documents are generally 2-3 pages each so if you choose to order these your cost should be around $10. Below I have included our website which contains information on how to obtain your medical records along with the associated costs.

Please note you may complete the necessary forms & take them to _____ or you may mail them into our processing center which is listed on page 2 of the authorization. If you chose to go to _____ to pick up your records we ask for a minimum of 2 business days to process your request, however we will attempt to process it same day if possible. Our campus is open Monday-Friday from 8am-3:30pm & closed from 12pm-1pm.

If you have any further questions please feel free to contact me.


Manager Release of Information

Email to hospital 4/19/11

I am still in the process of evaluating the medical records.

But the automated phone calls have resumed.

Please stop them.


Ira Man

Email to hospital after receipt of invoice 4/4/11

On 3/9/11, I notified Customer Service of my intent to dispute these charges.

Is there some formal notification process other than email required?


Ira Man


You will need to send a letter listing exactly what you are disputing and listing items that you are disputing and if billed what you did not receive. You can send the letter to the same address as is listed on our statement where you send payment on an account of _____.

Your account is already noted that you spoke to a financial counselor at _____ hospital on 03/07/2010 and you were informed that the pricing structure is not open for dispute. You stated to the financial counselor that your concerns were not regarding any fraud or malpractice on the hospital's part but did not give any specifics. Our charges are Medicare approved and are reviewed periodically to determine if they are in line with the demographic area in Central Florida.

Thank You,

Customer Service

Letter from hospital 4/18/11

Dear Mr. Ira Man:

Consistent with our philosophy, _____ hospital endeavors to provide quality health care to all we serve. Our records indicate several attempts have been made to contact you regarding the above-mentioned balance and we are contacting you in hopes that we can amicably resolve this matter. Nationally, most hospitals are turning their accounts over to bad debt agencies quicker, but we have decided to manage our volumes in-house by offering a variety of payment options up to including a health care line of credit.

Our timelines are critical and we want to encourage you to act within the next ten (10) days. In order to take advantage of these options, please contact our via telephone at _____ or email at: _____. We look forward to your prompt response to allow us to help you satisfy your obligation. If you have any questions regarding any patient portions deemed by your insurance carrier, please direct those questions to your insurance carrier.

If we do not hear from you within the above stated time frame, further collection proceedings will occur

up to including your account being referred to an external collection agency or possible litigation through court proceedings.


Senior Legal Assistant

Patient Financial Services

Legal Collections

"With a Little Help from My Friends" 1

As it turns out, one of the officers of the hospital lives just a few doors down from Ira. So, he took the letter down to the officer's wife and asked her to show it to her husband so that he could give Ira some guidance as to how to proceed. Ira told her that he would be going out of town in a couple of weeks for at least two months and didn't want to leave this matter unresolved.

A week later she told him that there was nothing that her husband could do since it was in collections.

Phone call to hospital

Ira placed a call to K M, (who had previously called and left her name and number), and explained that he had objections to the bill and wanted the hospital to seriously review his documentation. (Ira had built a web page containing much of what is in this book, and gave her a link to it.)

Email from hospital 5/3/11

Mr. Ira Man,

As I mentioned to you, I brought up your documentation at my meeting yesterday afternoon. The matter has been forwarded to Patient Relations. I don't expect to have any type of response for approximately 30 days.

The account has been placed in a HOLD status until a response in received at which time I will be back in touch with you.

Please feel free to contact me if you have any questions.


Manager, Legal Collections

Patient Financial Services

Email from hospital 6/10/11

Mr. Ira Man,

Please see the attached letter regarding the outcome of the review for account _____.


Business Analyst and

Assistant to C I

Dear Mr. Ira Man:

In response to the concerns you shared regarding your visit, our Patient Care Committee has reviewed the records. It has been determined that the balance of $6,016.34 remains as the patient responsibility.

Your account has been returned to K M, our Legal Collections Manager to continue with collection efforts. Please contact her to discuss your payment options.



Patient Care Coordinator

Patient Financial Services

"Of course you know, this means war" 2

Summary Claims Court 7/21/11

Ira filed a case in small claims court in which he claimed that the charges were arbitrary and so excessive that they should be abrogated by the court and replaced with charges that are reasonable.

Ira's claims:

    • Failure to provide a detailed explanation of the charges as provided under the Florida Patients Bill of Rights

    • Duplicate charges - charge based on condition and specific charges for each service

    • Not following medicare rules, as claimed by the hospital, which apply to all patients whether Medicare enrolled or not

    • Harassment by phone which is a violation of Florida law

    • Failure to provide a mediation and arbitration policy or grievance policy and inform patient of same

    • Failure to provide a single point of contact with the hospital ( who speaks for the hospital )

    • Charges that are not cost based

    • Charges that are not 'Usual' because they are not similar to other hospital charges in this region

    • Charges that are not 'Customary' because they are not collected routinely

  • Charges that are not 'Reasonable' because they are anywhere from 10 to 100 times the cost

Phone call from C I to Ira 8/25/11 ( two weeks before the pretrial conference )

During a somewhat heated discussion, Ira's issues were explained, apparently for the first time to C I. By the end of the call, a resolution had been proffered.

Letter from C I to Ira 8/26/11

"Thank you for bringing your matters to our attention", the letter began. Followed by some usual boilerplate and hard copy of the proposal.

"First, kill all the lawyers" 3

Summary Claims Court 9/9/11

Had it not been for the lawyer-demanded nondisclosure agreement, and the agreement not to disclose the nondisclosure agreement, and the discussions that were thereby generated, Ira would have cancelled the small claims case sooner. It was put to bed on this date, nine months after the ER visit.

1. Sgt. Pepper's Lonely Hearts Club Band, 1967

2. Bugs Bunny, Groucho Marx, ( dates unknown )

3. A popular misquotation of "The first thing we do, let's kill all the lawyers.", Shakespeare ( Henry The Sixth )

Price Transparency

A few Americans make huge fortunes from the high cost of medical care. Drug company and hospital CEO's, technology barons, and certain physician specialists come to mind. Except for those special interests, whose personal fortune is tied to high costs, it's in everyone's interest to reduce health care costs. Whether it is Medicare's impending financial crisis or simple affordability, something has to change. Everyone knows that the system is broken and getting worse. What middle class person can pay $16,000 for a 24 hour evaluation? One might ask: "Should I have this left arm pain looked at by a doctor to rule out a heart attack, or should I pay this year's college tuition for my child?" This is where we are.

Congress has made an attempt to address this problem by providing tax incentives for high deductible health insurance, under the assumption that when individuals pay their own bills, price competition will bring down costs.

The flaw in this logic is that there can be no price competition without price knowledge. You can't compare prices if you don't have a price list! With such a complex, disparate, pricing policy, only a medical billing expert could have such knowledge. But even then, prices would have to be published using standard identification codes or labels. Getting even the CPT codes, after the fact, required Ira to submit a HIPPA form. Whether this hospital is hiding behind the HIPPA law or scrupulously following it, is in the eyes of the beholder. But price transparency, nonetheless, is the victim.

And then there is the ambivalence of the people in charge of the hospitals, to wit:

{ Once a commitment is made to quality and transparency, it must be maintained. However, the information must be put into context. Price comparisons should be severity adjusted, or at least case-mix adjusted. Quality measurements should show what they indicate and how they work. The hospital should publish a trend report on its quality indicators tracking progress and an explanation, not excuses, if changes are not occurring. This report would be sent to business and thought leaders in the community on a quarterly basis. A report on pricing would also be sent out, showing factors that cause the prices to be high and making sure that proper comparisons are made in the areas of charity care, Medicare and Medicaid volumes and self-pay as well as intensity of care. Finally, the board chair should meet with the editorial board to discuss the information and to make sure that the press understands all the issues.

Rich Morrison

CEO, Florida Hospital,


Any information we release regarding cost, safety and efficacy must be presented within the context of our mission. Our mission is critical and simply different from the missions of other hospitals in our region. We are responsible for the training and education of the next generation of pediatricians and health care leaders for this nation. We are a facility that is dedicated to research. We also serve more indigent and Medicaid families than other facilities, and we see more acutely ill patients in the subspecialty areas. It's important to allow the consumer and the media to be able to compare apples to apples regarding cost and quality, and so stating which facilities we should be compared with is important. Transparency is important. Withholding information doesn't help, it has a tendency to come out anyway and it is far better to be ahead of that curve. But we must be careful to release information in such a way that our key story is told.

Kevin Churchwell

CEO, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn.

{see: Will Bad News Slow Transparency}


Perhaps one of the reasons that hospital bills are so high is because hospitals have a tough time collecting. They raise charges to compensate and the percentage of payment goes down. So they raise charges again and the cycle continues. These bills are now beyond the ability of the average person to pay. He may just give up and pay nothing. Bankruptcy has, in many cases, become the method of settlement. The victim's credit is ruined and the hospital gets pennies on the dollar.

Collection agencies may be another reason. There are primarily two ways collection agencies can collect from victims.

    1. Contingency fee in which the agency gets a percentage, in the order of 35% of money collected.

    2. Debt purchase in which the collection agency buys the debt from the creditor ( hospital ) for what is, in some cases, roughly 6% to 7% of the total debt.

The hospital may set their break-even point at 10% of charges. Therefore, selling the debt to a collection agency enables break-even on a patient without the ability to pay. This "imputed loss" of 90% of charges might be used to offset profits in other areas in order to demonstrate to government a reported 3% annual profit.

Had Ira been one year older and fallen under the "protection" of Medicare pricing, the hospital would have received approximately $1,000 to $1,500, about 10% of Ira's bill. The pricing rationale seems obvious. For self-pay and insured patients, move the decimal point one position to the right.

The hospital has an incentive to compromise, in private. Going public with negotiated settlements undermines what limited integrity the pricing structure has. It's all part of the game.

{ see: }

Florida Patient's Bill of Rights and Responsibilities.

Florida Statutes Chapter 381(026)

Purpose Of The Florida Patient's Bill Of Rights And Responsibilities

It is the purpose of this section to promote the interests and well-being of the patients of health care providers and health care facilities and to promote better communication between the patient and the health care provider. It is the intent of the Legislature that health care providers understand their responsibility to give their patients a general understanding of the procedures to be performed on them and to provide information pertaining to their health care so that they may make decisions in an informed manner after considering the information relating to their condition, the available treatment alternatives, and substantial risks and hazards inherent in the treatments. It is the intent of the Legislature that patients have a general understanding of their responsibilities toward health care providers and health care facilities. It is the intent of the Legislature that the provision of such information to a patient eliminate potential misunderstandings between patients and health care providers. It is a public policy of the state that the interests of patients be recognized in a patient's bill of rights and responsibilities and that a health care facility or health care provider may not require a patient to waive his or her rights as a condition of treatment. This section shall not be used for any purpose in any civil or administrative action and neither expands nor limits any rights or remedies provided under any other law.

Rights Of Patients

Each health care facility or provider shall observe the following standards:

Individual dignity

    1. The individual dignity of a patient must be respected at all times and upon all occasions.

    2. Every patient who is provided health care services retains certain rights to privacy, which must be respected without regard to the patient's economic status or source of payment for his or her care. The patient's rights to privacy must be respected to the extent consistent with providing adequate medical care to the patient and with the efficient administration of the health care facility or provider's office. However, this subparagraph does not preclude necessary and discreet discussion of a patient's case or examination by appropriate medical personnel.

    3. A patient has the right to a prompt and reasonable response to a question or request. A health care facility shall respond in a reasonable manner to the request of a patient's health care provider for medical services to the patient. The health care facility shall also respond in a reasonable manner to the patient's request for other services customarily rendered by the health care facility to the extent such services do not require the approval of the patient's health care provider or are not inconsistent with the patient's treatment.

    4. A patient in a health care facility has the right to retain and use personal clothing or possessions as space permits, unless for him or her to do so would infringe upon the right of another patient or is medically or programmatically contraindicated for documented medical, safety, or programmatic reasons.


    1. A patient has the right to know the name, function, and qualifications of each health care provider who is providing medical services to the patient. A patient may request such information from his or her responsible provider or the health care facility in which he or she is receiving medical services.

    2. A patient in a health care facility has the right to know what patient support services are available in the facility.

    3. A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient, in which case the information must be given to the patient's guardian or a person designated as the patient's representative. A patient has the right to refuse this information.

    4. A patient has the right to refuse any treatment based on information required by this paragraph, except as otherwise provided by law. The responsible provider shall document any such refusal.

    5. A patient in a health care facility has the right to know what facility rules and regulations apply to patient conduct.

    6. A patient has the right to express grievances to a health care provider, a health care facility, or the appropriate state licensing agency regarding alleged violations of patients' rights. A patient has the right to know the health care provider's or health care facility's procedures for expressing a grievance.

    7. A patient in a health care facility who does not speak English has the right to be provided an interpreter when receiving medical services if the facility has a person readily available who can interpret on behalf of the patient.

Financial information and disclosure

    1. A patient has the right to be given, upon request, by the responsible provider, his or her designee, or a representative of the health care facility full information and necessary counseling on the availability of known financial resources for the patient's health care.

    2. A health care provider or a health care facility shall, upon request, disclose to each patient who is eligible for Medicare, in advance of treatment, whether the health care provider or the health care facility in which the patient is receiving medical services accepts assignment under Medicare reimbursement as payment in full for medical services and treatment rendered in the health care provider's office or health care facility.

    3. A health care provider or a health care facility shall, upon request, furnish a patient, prior to provision of medical services, a reasonable estimate of charges for such services. Such reasonable estimate shall not preclude the health care provider or health care facility from exceeding the estimate or making additional charges based on changes in the patient's condition or treatment needs.

    4. A patient has the right to receive a copy of an itemized bill upon request. A patient has a right to be given an explanation of charges upon request.

Access to health care

    1. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.

    2. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide such treatment.

    3. A patient has the right to access any mode of treatment that is, in his or her own judgment and the judgment of his or her health care practitioner, in the best interests of the patient, including complementary or alternative health care treatments, in accordance with the provisions of s. 456.41.

Experimental research

In addition to the provisions of s. 766.103, a patient has the right to know if medical treatment is for purposes of experimental research and to consent prior to participation in such experimental research. For any patient, regardless of ability to pay or source of payment for his or her care, participation must be a voluntary matter; and a patient has the right to refuse to participate. The patient's consent or refusal must be documented in the patient's care record.

Patient's knowledge of rights and responsibilities

In receiving health care, patients have the right to know what their rights and responsibilities are.

Responsibilities Of Patients

Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows:

    • A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.

    • A patient has the right to a prompt and reasonable response to questions and requests.

    • A patient has the right to know who is providing medical services and who is responsible for his or her care.

    • A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.

    • A patient has the right to know what rules and regulations apply to his or her conduct.

    • A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.

    • A patient has the right to refuse any treatment, except as otherwise provided by law.

    • A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.

    • A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.

    • A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.

    • A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.

    • A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.

    • A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.

    • A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.

    • A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.

    • A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.

    • A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.

    • A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.

    • A patient is responsible for following the treatment plan recommended by the health care provider.

    • A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.

    • A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions.

    • A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.

    • A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.


Reducing radiation risks


Finger Lakes Health Systems Agency




Brilliance 64-slice CT Scanner by Philips


Costs vs. Benefits: Comparing 64-Slice to 256, 320-Slice CT | Scranton Gillette Communications: ITN and DAIC


GE Healthcare-Product Technology-Non-invasive Solutions


Too Many Unnecessary MRIs and CT Scans? - CBS Evening News - CBS News


Doctor Self-Referrals Part of Health-Care Cost Trend -


Hospital board CT scanner purchase


CT scanner useful life 5 years


Will Bad News Slow Transparency?


Hospital Inpatient Health Care Consumer Initiatives


Emergency Medicine | Correctly Apply 99285 Acuity Caveat to Optimize E/M Coding


ED Facility Level Coding Guidelines CPT 99285


EMTALA | American Academy of Emergency Medicine - AAEM CPT 99285 Medical decision of high complexity


Observation Care Payments to Hospitals FAQ


Scan Cost

CT scanner cost approx. $1,000,000 { see: Costs vs. Benefits, and normantranscript below }

Figure 5 years useful life

$200,000 per year or $550 per day

Figure 20 to 40 scans per day { see: FINGER LAKES, below }

Pro rata cost equals $14 to $28 per scan


Costs vs. Benefits: Comparing 64-Slice to 256, 320-Slice CT | Scranton Gillette Communications: ITN and DAIC

Reducing radiation risks