Blogging astronomical medical bills.
Editor’s comment: After last week’s KC&A Update article about what appears to be intentional overbilling for implants, we got the following responses from you and provide our thoughts:
1. Who was the surgeon? I ask because Dr. X did an IME on a claim I recently received. He is recommending a “hybrid procedure” which is a 1 level disc replacement and a 1 level fusion directly below. According to his office he charged a patient for a similar procedure in December $137,000 for the surgeon fees. The assistant fee would be 20% of the surgeon fee. Between the doctor and his assistant we would be looking at $164,400! That does not include the hospital or anesthesia or anything else. Of course now my injured worker would like to treat will Dr. X. The only good thing in all this is that I can tell him no.
From our perspective, surgeon’s bills are coded and covered by the Illinois Medical Fee Schedule and they can’t charge whatever they want. The assistant’s participation and fee should be a subject of UR.
2. One strong overall suggestion was for major self-insured employers to try to find a way to pay/process WC medical bills under group coverages and then have WC reimburse your group people. We will bet major self-insured employers are effectively self-insured for both workers’ comp and group health care payments. No group carrier would ever pay what you are being asked to pay for WC care in this goofy state—they would straighten the hospital out and pay a much lower cost. Trust me, it isn’t happening by mistake that hospitals and doctors are billing so much money when they know it is a WC claim—they are opening playing to the system that treats employers in this state so poorly.
From our perspective, we are looking for any major self-insured employer to provide input on this concept. Is it “legal” to do so? Wouldn’t the savings be enormous? What if they gave a Medical Fee Schedule and no one showed up?
3. Three of the major “benefits” that were to accrue to the employer community as a result of the adoption of the medical fee schedule were that:
(1) It would set a baseline (capped) price;
(2) It would limit the growth in expense to CPI-U; and
(3) Price increases would be limited to one per year.
It greatly surprised (and dismayed) the employer community when the Commission announced via the rulemaking process that certain “carved-out” revenue codes* would be paid at 65% of billed charges. Clearly, a percentage based payment with no controls does not comport with the statutory intent—providers may raise prices as often and as much as they wish to meet their then current revenue goal. Under these circumstances, nothing prevents a provider from targeting a revenue goal that makes up for any perceived slights in the rest of the fee schedule.
The hospital fee schedules were created using Illinois Department of Public Health data. At the time the schedules were created, the Commission said that it removed charges related to the carved-out revenue codes from the data to insure that there was not a duplication of expense. Thus, we know that the Commission has the capacity, using IDPH data, to determine whether there have been wholesale and/or egregious increases in the carved-out revenue codes. Further, the IDPH data is at a level where the individual hospitals can be identified (not by the public, but by the Commission).
What prevents the Commission from examining this issue as part of the report to the Governor and General Assembly that is due by January 1, 2010?
Are hospitals taking advantage of this provision in the rules? What have price increases in these revenue codes been since the implementation of the schedule? Is this a flaw in the implementation of the statute that needs to be corrected?
This comment came to us from one of Illinois’ most knowledgeable experts on the Medical Fee Schedule. To answer her questions:
A. What prevents the Commission from examining this issue as part of the report to the Governor and General Assembly that is due by January 1, 2010? We still feel the IWCC is not run by people who care about the Medical Fee Schedule and saving money for Illinois business—it is run by the other side of the bar who are trying to make as much money as possible in a tough economy. In our view, they aren’t going to care about this issue or want to report it to the Governor and legislature. We will have to see.
B. Are hospitals taking advantage of this provision in the rules? Some hospitals clearly appear to be doing so—you can’t hide the fact the many bills we received were charging amounts like $166,000 for “implants” when the rest of the bill was a third of the cost. Even paying at 65%, this markup is wildly high.
C. What have price increases in these revenue codes been since the implementation of the schedule? To our knowledge, “implant” makers kept their products out of the codes.
D. Is this a flaw in the implementation of the statute that needs to be corrected? Yes, it is one of a number of flaws that no one appears to be addressing in any way. We are writing this article hoping someone takes notice and does something to close the gaps. Illinois also needs a prescription medical fee schedule.
