“Go to Ambulatory Care, second floor,” he said as he wrote the time and place on the back of an appointment card. Our new family doctor is young and uses technology often. He carries his laptop computer around the office and uses his cell phone to contact people to get appointments started. He’d just prescribed a nerve pain medication for my husband’s throbbing feet and used the speaker setting on his cell phone to talk to someone about scheduling an appointment with a podiatrist.
When we got home I called the podiatrist to discuss costs. We’re on a very tight budget and my husband has no health insurance. I wanted to know how much we should expect for the initial visit. After several questions were answered I relaxed confident they’d work with me.
A week later we arrived at the hospital and took the elevator up to the second floor. With the help of a stranger in the hallway we found our way to Ambulatory Care. The nurse escorted us into a room across from the nurse’s station. As we politely made our hellos she directed me to a seat nearby while she weighed my husband and took his blood pressure.
“Oh,” she said, ” I need to give you this.” She handed me a clipboard that held a page of privacy information and a letter from the podiatrist’s office. The letter clearly explained that we’d be receiving two bills for today’s services. One bill from the doctor and another from the hospital.
“This letter is very helpful,” I said. I was trying to remain calm but inside I was starting to panic. “It would have been really helpful had we gotten it sooner. The letter states that there will be additional charges for using your facilities. If I had known this ahead of time I’d driven 40 miles to the University.” The realization had started kicking in. We were in a hospital. I was starting to see dollar signs.
The nurse appeared to stiffen at my sudden change in mood. She mumbled something about she didn’t handle billing but she’d call down and have someone talk to us. Then she hustled us down the hall into a hospital room. She seemed relieved to turn us over to another nurse as she made her exit. The second nurse pointed to the bed and instructed my husband to sit there. She handed him a clipboard which he handed to me. I sat in a chair nearby and became increasingly annoyed.
“Why do they need all this stuff?” I complained. “It’s an ingrown toenail for Pete’s sake.”
The nurse ignored me and started questioning him. “What medications do you take?”
She stood by a computer and typed in his responses. She had just finished her do-you-smoke-and-how-much questions when a young lady walked in, said she worked in billing, and had been called to come talk to us.
I explained that my husband no longer had insurance, that it had disappeared with his job when the plant closed down. “We’d like to have insurance, ” I said, “but if you don’t belong to a group the costs are not affordable. Add in a pre-existing condition and we’d have to be homeless and stop eating to afford it.” She chuckled, but I wasn’t exaggerating.
“We have a great financial assistance program,” she offered.
“We won’t qualify,” I countered. “Most programs only look at income and disregard costs. None of the programs consider my medical costs which already take 30% of our monthly income up front.”
I went on to tell her how I felt we’d been duped. I was pretty sure whatever they planned to charge for this visit would be more than the cost of gas even at today’s prices. Most of the specialists who practice here maintain their offices in a city about 40 miles away. These specialists come up once or twice a week to serve patients from this area. I’d seen specialists in town myself so I hadn’t thought much about particulars before now. I began to sift through my memories and two thoughts jumped out at me: (1) I had had health insurance. My husband didn’t. (2) I had seen a specialist in another building in town, not within the hospital itself.
She talked and talked and tried to reassure us. I started wondering if it was costing us to listen while she rattled.
“Do you want to file a complaint?” she asked.
“I don’t want to be black-listed,” I said. “We may have an emergency someday and have to use you again.”
“You won’t be black listed,” she said. “We don’t do that here. The complaint allows us to learn what people care about. It would actually help us to understand how to improve.”
“Should we file a complaint?” I asked my husband.
“Might as well he said.” She said she’d write it up and finally left the room. As soon as she left the podiatrist stepped in. His visit only lasted a few minutes and most of that was spent answering our questions. I stood beside him so I could see up close what he was doing with the toenail. He pulled out a pair of scissor-like clippers and quickly cut away the ingrown toenail, then scraped away any dead skin around it.
“I like this doctor,” I thought. He was pleasant and seemed to know what he was doing and I knew I’d seen those very same clippers at Walgreens for $20. When the doctor said my husband’s feet looked good over all and he wouldn’t need a follow up, I knew I’d be buying a pair of clippers at Walgreens soon.
Two days ago I got the bill from the doctor’s office. They had given a 25% discount because he didn’t have insurance. To get their money quickly they also offered another 20% off the total if we paid it within 30 days. With the two discounts the doctor’s bill was $109. 80. I had no complaints and thought his bill was fair and reasonable.
I woke yesterday morning wondering what the hospital costs would be. I hadn’t heard from them so I decided to call and find out. The lady that answered the phone in billing turned out to be the same one we’d talked to at the hospital. She gave me a total cost of $232.28 for the hospital’s part. I told her that was more than double what the doctor charged. I reminded her of the letter that the hospital presented at the appointment itself and reiterated that had I gotten it sooner, we would have made a different choice. She sounded sympathetic and put me on hold while she went to find her supervisor.
When the supervisor got on the line, I explained the situation to her from start to finish. The supervisor pointed out that the figure I’d been given already included a 25% discount because he didn’t have insurance. I suppose she intended to show they were giving me a deal, but I didn’t see it that way.
“What was it before?” I asked.
“I can send you an itemized statement if you’d like,” she said.
“Have a pen and paper right here,” I said. “Read it to me.”
She read the information and I wrote it down. The original bill was a total of $309.71. This total included $135.90 as their cut of the “procedure” which was the podiatrist clipping out that ingrown nail. Then there was a charge of $173.81 for the room, nurses, and any supplies we used. The 25% discount brought the total down to the previously mentioned total of $232. 28. When I stated that it didn’t seem right, her tone became dismissive and sounded a bit condescending.
“Don’t get curt with me,” I calmly said. “I have a legitimate concern and you need to listen to it.”
“I’m not being curt,” she said. “I’m just trying to explain.”
“You have a tone in your voice,” I said. “You were short with me and you sound like you’re telling me how it is.”
“It’s not that,” she said. “I just want you to understand that the doctor is new here. His office should have prepared you.”
“I’m okay with the doctor’s bill,” I calmly said. “It’s your bill that I have an issue with. You sound like you’re trying to blame the doctor. I was told that the letter you gave me at the appointment came from his office, so he was at least attempting to let us know. I didn’t get any notice, timely or otherwise from you guys, and it’s suspicious that you held on to it until we arrived.”
After a longer discussion with her continuing to blame the podiatrist, she finally said she could authorize an additional 40% discount. This would bring the amount we owed the hospital down to $139.36.
“That’s not good enough,” I said matter-of-factly.
“Well, that’s the best I can offer,” she said.
“Who is your supervisor?” I asked.
“My supervisor? Molly,” she said, ” and if Molly isn’t here, it’s Tina.”
“Who is your supervisor today?” I asked.
“I’ll have to find her,” she said. “I’ll have her call you in a few minutes.”
“That’s good,” I said. “I’ll be expecting her call. This isn’t going to stop until I’ve resolved the issue.”
“I think I’ll call the podiatrist’s office and find out what their facility would have charged if you’d gone down there,” she added.
I thought that sounded like a really good idea, but I decided not to take her word for it. I called the podiatrists’s office myself and was routed to financial counseling. I explained right up front that I had no issue with their billing. I explained the situation and made an off-handed comment that lightened the mood. Tammy looked up the information and explained that the usual clinic fee across the board is $80 to use their facility, but they offer a 45% discount to uninsured patients which brings it down to $44.
“So if I had gone there instead,” I said, “it would have cost the doctor’s bill plus $44?”
“That’s right,” she said. Tammy gave me her last name and a number that would go directly to her. While I was on the phone with Tammy my call waiting started beeping. I checked the number after we were through talking and dialed it back.
Molly was polite and seemed interested in resolving the issue. She listened to my story and offered that someone from their financial assistance program should be contacting me. I told her they had called while we were out and had left a number to call back. I’d tried the number and sat and listened to their “your call is important to us” recording for half an hour before they told me no one was available to take my call.
“They told me to leave a message,” I said. “They could have told me I wasn’t going to talk to a person 20 minutes sooner. I was so annoyed I just hung up, but they kept telling about their website on the recording and I wrote it down, so when I hung up I went to my computer to check it out. Your financial assistance program is run by a private company your hospital contracts with. They train your personnel to collect money. On the website when they talk about their clients they are talking about you (the hospital), not my husband, the patient. I read that letter from the executive chief of the company. He talked about how their clients have made billions of dollars using their program.”
Mary was very quiet but I could tell she was still there so I continued.
“Hospitals get their money mostly from insurance companies and from the government through medicaid. Patients that have insurance don’t think about the costs and people on medicaid are just glad to get some relief from their misery. People who qualify for medicaid are too poor to buy computers and pay internet charges so they probably don’t read stuff on your website. I’m not against hospitals making money. I understand you have to pay salaries and make a profit, but people like us who have lost their insurance do not have the deep pockets that big insurance companies and the government do.”
I was candid but kept an even tone to my voice. (Emotional rants rarely do more than just push people into their own corners.) Molly returned the attitude in kind but she continued the same “blame the new guy” approach.
“Your hospital has had specialists coming up here forever,” I said. “I don’t believe you’ve never come across this issue before. Stop blaming the specialist. I’m not buying it. I was told in the hospital that the letter came from his office. You guys just held on to it until I arrived. I got nothing from you one way or the other.”
Next she said something that implied my family doctor was to blame. “He should have informed you there would be additional charges when he set up the appointment.”
Tired of this refusal to accept their role I decided to put an end to it.
“Would it be fair to assume your hospital encourages its doctors to use your facilities?” I asked.
“Yes, ” she agreed.
“And it seems logical to me,” I continued, “that it would go against the hospital’s interest to inform your doctors that sending patients to you will cost us more. People who sell things for a living don’t profit well by being up front with potential buyers. I doubt my doctor realizes how much more it is costing his uninsured patients to go to your hospital for these small services. He knows our situation and has been reasonable and supportive so far. I’m just glad my husband didn’t need surgery. If the podiatrist had drawn blood no telling how much more money you guys would have duped us out of.”
I told Molly that I thought since he made the appointment that I did agree that he should be informed about this, so I would be calling our family doctor too.
“You’re calling your family doctor?” she asked.
“Yes,” I said. “Right after I hang up from talking to you. I have the appointment card he gave me right here. The time and place were set up while we were at his office. I don’t think he knows how much a difference in price there is. He needs to know how big a difference there is.”
Molly promised to get back to me or someone would get back to me soon. She wrote down Tammy’s full name and I gave her the phone number that would go directly to her.
It was almost noon by then so when I called my family doctor’s office, he had gone to lunch. I got his nurse instead. Bonnie had worked for our previous doctor before he retired so she knew us. I explained the situation and gave her all the figures which she wrote down. She shared that he had just had to deal with another situation between the hospital and one of his patients. She didn’t explain, of course, but it was clear that my doctor has just recently been involved in some other issue with the hospital. She assured me she’d tell the doctor when he got back from lunch.
I took a break too and prepared a lunch for the two of us. We’d just finished eating when the phone rang. The lady who called identified herself as the Director of Ambulatory Services. She said she had been informed about my concerns. She also had a message on her desk to call my family doctor, but she hadn’t called him yet. She wanted to hear from me first.
“It’s kind of a long story now,” I said.
“I’ve got time,” she said.
I was candid but polite. I told her how the letter being presented at the opening and then people trying to blame ‘the new guy’ made things appear deceptive. She assured me it wasn’t intentional, but agreed that perceptions are what matter. She shared her own frustrations that people don’t report concerns, but just complain among themselves.
“So you’ve done a good thing,” she said. “I’ve talked with Tammy and she verified what you told Molly. I have also talked with our executives and they agree that we need to offer the same costs and discounts to the uninsured as they do down there. We don’t want to lose patients because they are driving somewhere else. You will receive a bill from us for $44. You have not only helped yourself today, you’ve helped other uninsured people as well.”
I thanked her for her time and patience. I feel good about this, but know it’s only a promise until it works for others too. I know I’ve rattled the cage though and suspect my doctor is rattling his own cage as well. I’d like to believe that people will try to do better but sometimes they just get sneakier. Today when I went back to the website to find that phrase about how “their clients have made billions” it had been edited out. I’m not sure who they think reads that website but they are already making changes to it. That was yesterday. I got my bill from them today. Amazing how quickly they can move to get this issue behind them.
- Hospital Fees and the Uninsured (lawprofessors.typepad.com)
- Tens of thousands die in the US due to lack of health insurance (theaveragejoenewsblogg.com)
- Can one person make difference? (howgoesthebattle.com)