Hello everyone!
I apologize if this topic has been covered before; this is my first post here and I may not have searched properly.
Long story short, over the past two years I’ve needed multiple surgeries and hospital stays to address health problems extremely uncommon for a 31 year old male (e.g. a 2 foot fall causing a hip dislocation and pelvis shoulder fracture, chronic back pain and leg pain from severe spinal stenosis). Between those events and the (still ongoing) fight through medical negligence, gaslighting, and doctors lying about the existence of FDA indicated treatments in place of risk management, I’ve developed iatrogenic, (i.e. heath care caused) cPTSD. My psychiatric NP recommended I try to channel it towards patient safety and advocacy as one therapeutic path.
I’m not looking to get any compensation or credit out of it. I would just like the information to get to as many people as possible. It’s disgusting to me that hospitals can get away with so much exploitation of vulnerable people and inelastic demand. I’ve never made any public content before though, so I have no idea how any of that side of it goes 
I thought it would be best to start on the topic of hospital billing fraud. That is perhaps the only “black and white” issue at play. My thought was that by highlighting an issue that is literally a yes or no question of “is the hospital complying with federal regulations on healthcare prices,” a consumer could push back with more confidence. Ideally I could help limit the chance they may lose hope by showing a path that doesn’t require them to hire anyone on their behalf and where they don’t have to refute any obfuscation the hospital throws back. Is that the best starting point in your opinion? Is there a better way to frame it so people don’t feel overwhelmed?
Particularly, I would focus on hospital’s unwillingness / laziness to comply with the recent Hospital Price Transparency legislation. In all my visits to a hospital since that law passed, I have been significantly overcharged. The body of the regulation can be found in Title 45 CFR Part 180.50. Here is roughly the chain of events:
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I receive an bill. I call and request an itemized bill. Regardless of whatever the person on the phone says, hospitals are legally required by HIPAA to provide you one. I personally have never had any issue in getting an itemized bill. If you do, I’d recommend to exhaust all the normal options - reminding them of the law, asking for a manager, etc - but end the conversation (ideally in writing, but always write down the date, time, staff member of the call) saying you wish to honor the agreement you made to be responsible for payment. Your institution’s refusal to comply with federal law is prohibiting me from knowing what that responsibility is. I must refuse take ownership or responsibility of non-itemized charges as to do so would force me to violate our financial agreement.
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Go and find the “standard charge file” on the hospital’s website. Do not use the “Price Estimator” tool. You are specifically looking for this requirement to be met:
(1) A hospital must establish, update, and make public a list of all standard charges for all items and services online in the form and manner specified in this section.
(2) Each hospital location operating under a single hospital license (or approval) that has a different set of standard charges than the other location(s) operating under the same hospital license (or approval) must separately make public the standard charges applicable to that location.
There are no “estimated charges” in this file (again, ignore the hospital if they say this). It will be a large data file that will likely be in a very ugly format. (Though they added extra regulations this month to make the file easier to use). It is going to have a lot of unnecessary information, so don’t let it scare you off. All you really need is the CPT / Inventory / Drug codes and the cash price column.
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Once you pull out that information - go back to your itemized bill. Go through each line of your itemized bill - look up the relevant code and compare what they charged you to what they have listed in that file. (This will be tedious to do manually; I just write some R code to do it but unfortunately the data inputs wouldn’t be consistent enough for me to write a one-size-fits-all script :-/)
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Don’t get distracted by the insurance adjusted columns - they aren’t necessary to see if the hospital is overcharging you. If they have any items on your bill charged at a higher price than what’s listed as the cash price in the Standard Charge File - that’s fraud. The CFR requires that file to be updated at least every 12 months. It is the hospital’s responsibility to update that file any time prices are increased. If they neglected to update that file, they can still only charge the amount that’s posted the day your statement is dated (so be sure to keep copies of the files, when you downloaded them in the metadata, etc)
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Contact the hospital, file an official grievance (always go for email vs a phone call if you can since most things are required to be “written” ) and similar to the proposed argument above - state that the itemized bill you received has fraudulent charges on it and therefore you are forced to insist they provide a legally compliant bill to allow you to complete your agreement for payment.
**Caveat: I ignored their threats to go to collections because they can’t collect on a debt they cant establish I am responsible for. Nothing came of it. I’m not an expert on the legalities of credit reporting or how to deal with fraud there. Maybe someone can step in from here on that?
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They can’t ignore your grievance. Per Title 42 CFR § 482.13 section (a),
“(i) The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital.
(ii) The grievance process must specify time frames for review of the grievance and the provision of a response”
Issuing a grievance on fraudulent billing charges, per the regulations, should put a stop to them trying to collect on the bill until the grievance is resolved (and you have a copy of all actions taken, results, decisions, etc in writing with a wet signature from someone on staff). But hospitals usually farm out bill payment to debt collection companies anyway, so you might have to remind the billing folks. -
The hospital will hem and haw and try to come up with a whole bunch of nonsense reasons as to why they aren’t actually violating regulations. But they will be. They will also likely be violating the internal policies of the hospital system itself. (i.e. the grievance not being completed per the time limits set by the hospitals policy). Try asking for those. They don’t have to give you those, but if you bug people enough they might send them over just to get you off the phone.
There are also plenty of resources you can send them that will cover the major excuses. This was very handy (https://www.cms.gov/files/document/hospital-price-transparency-frequently-asked-questions.pdf) for things like: “Hospitals must make public both of the following: (1) A machine-readable file containing a list of all standard charges for all items and services as provided in 45 CFR §180.50 and (2) a consumer- friendly list of standard charges for a limited set of shoppable services as provided in 45 CFR §180.60” explains how simply having a price estimator tool is not sufficient for the requirements.
If all else fails, report the hospital to the Center for Medicare and Medicaid Services and wait. They dragged their feet at first, but they are finally getting around to actually going after hospitals with very steep monetary penalties. (Enforcement Actions | CMS)
There are also organizations like the Joint Commission you can report safety violations to. Though in my experience, the only thing that makes hospitals actually concerned with what you have to say is if your actions could threaten all that sweet sweet Medicare money they take in.
I didn’t really do a great job summarizing it there - I still can’t really bring it up without turning the dial on my emotions up yet. But as a general concept, would it be helpful for people to be aware of? Or is there an avenue or platform that already exists that could be used to help spread the education?
I appreciate you taking the time to read through this and offer any feedback!
Thank you!