Where the Frauds Are All Legal – The New York Times

5. The Enforced Upgrade

One Monday when Andrej was in pain and out of pills, the trauma doctor suggested we meet in the emergency room, because the trauma clinic was open only from 8 to 10:45 a.m. on Wednesdays and Thursdays.

So we met the trauma doctors in the E.R., and they talked to Andrej, who remained in his street clothes. They gave him a prescription. Because the interaction which could have happened in the lobby happened in the E.R., it resulted in an E.R. visit charge of $1,330. But when the trauma clinic is open less than six hours a week, billing for an E.R. visit that doesnt tap into any of the emergency room resources feels like a scam. Is an E.R. visit determined by the content of the services rendered, or merely by the location?

Andrej had a similar experience when his broken finger was treated with a plastic splint that folded over his fingertip. He complained because the upper layer pressed on the fracture. At a follow-up visit, someone took a pair of scissors and cut off the upper half of the splint and taped the lower half back in place. That translated into a $481 charge for surgery, in addition to the $375 charge for the office visit and a $103 facility fee. Doesnt surgery, by definition, involve cutting into flesh or an animate object not a piece of plastic?

Sure, it sounds fancy to upgrade a meeting to an E.R. visit, or to call the tweaking of a splint surgery, but if an airline overbooks my flight and puts me on another flight where the only seat available is in first class, it does not charge me for the more expensive ticket.

My insurer paid for most of these questionable charges, though at discounted rates. But even a discounted payment for something that never really happened or didnt need to happen or that we didnt agree to have happen is still, according to common sense, a fraud.

Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because its not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern about your well-being, as one benefits manager enlightened me: Theyre too big to care about you. Electronic records, which auto-fill billing boxes, have probably made things worse. For example, the birth of a baby boy may automatically prompt a bill for a circumcision; having day surgery may prompt a check for sedation.

So what is the appropriate payment for swag I didnt ask for, outrageous cover charges, stand-in doctors, drive-by visits and faux surgery? In some cases, zero; in others, far less than was paid. And yet, these are all everyday, normal experiences in todays health care system, and they may be perfectly legal. If we want to tame the costs in our $3 trillion health system, weve got to rein in this behavior, which is fraud by any other name.

Elisabeth Rosenthal, a former New York Times correspondent, is the editor in chief of Kaiser Health News, the author of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back and a contributing opinion writer.

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Where the Frauds Are All Legal - The New York Times