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It’s enough to make you swear: the complexities of medical billing and out of pocket costs

It is quite possible that reading this article about the complexities of medical fees will furrow your brow and possibly even give you a headache. The issues it canvasses left at least one hospital executive sighing and swearing.

And that is the point – medical billing is so complex that it is not well understood even by those running health systems and services. This complexity makes it almost impossible to achieve what sounds a deceptively simple ask: the upfront disclosure of out of pocket (OOP) medical costs.

As lawyer and medical billing expert Margaret Faux writes below in her latest contribution to Croakey’s ongoing #OutOfPocket series, we won’t be able to address OOPs until there are efforts to address “an extremely low level of legal literacy in the medical billing space, including by those tasked with reform”.

In the meantime, Faux writes, we can have either a single fee and multiple gaps – or multiple fees and a single gap. But not both.


Margaret Faux writes:

Up front disclosure of out of pocket medical expenses (OOPs) is not an unreasonable aspiration. Those in need of medical care anywhere in the world should be able to find out what they may have to pay from their own pockets, where possible, before they make decisions on whether to proceed with tests and treatments.

MargaretFaux
Margaret Faux

In Australia, various organisations are currently demanding action on this issue, as our OOPs continue to rise. Not surprisingly, some groups within the medical profession are pushing back.

Whilst the position of angry Australian consumers facing unexpected OOPs is easy to understand, the position of medical groups is less so. Why won’t they just put their prices on their websites like everyone else?

The easy assumptions and most popular rhetoric to answer this question usually includes predictable cries of greed and rorts by a profession out of touch and only interested in maintaining the status quo and their right to charge as they wish.

But it’s just not that simple.

Australian medical specialists, in particular, do have some legitimate concerns about how any proposed fee disclosures would work, because of the unique way in which some of our health financing arrangements operate.

The AMA president alluded to these issues when he was recently quoted in the following terms:

Dr Gannon said he charged 16 different fees for delivering a baby depending on the health fund a woman belonged to. Doctors who participated in no gap schemes had to set their fees within the parameters set by the funds and this meant there was no uniform charge, he said.”

He is right. And a conversation I had just yesterday with a hospital CEO (we’ll call him “Joe”) beautifully illuminated what the AMA’s Dr Michael Gannon was trying to explain in a 10 second sound bite.

By way of context, Joe was heading into a meeting with one of the anaesthetists who charges OOPs to patients having procedures at Joe’s facility. There had been numerous complaints and Joe was concerned about potential reputational damage.

Notes of a tortuous conversation

Here’s the transcript from my scribbled notes, recorded shortly after our conversation.

Joe:          I want him [the anaesthetist] to pay the money back to the patients, and I’m also going to speak with our proceduralists and tell them they have to tell their anaesthetists to stop charging gaps.

Me:          So are the proceduralists charging gaps?

Joe:          No, they’re all doing no-gap for all patients at our facility. They agreed to that.

Me:          Amazing! But I think it will be hard for the proceduralists to convince the anaesthetists to stop charging gaps, because they’re all independent business people entitled to set their own fees you know. But tell me, do your proceduralists always work with the same anaesthetists?

Joe:          No, they use an anaesthetic group that provides anaesthetists for us, so there are different doctors all the time.

Me:          Yep, that’s pretty common. Anaesthetists move around, and a lot of facilities do that. Do the anaesthetists all charge gaps or just this one?

Joe:          It varies, but most of them charge gaps.

Me:          Would it be possible to change the anaesthetic group they use do you think? That would be the simplest solution. Could you ask them to consider that?

Joe:          Nope. There is a contract and a history.

Me:          OK, so you’re stuck with them for now. How much are the gaps?

Joe:          In the range of $200-$250, but on average about $200.

Me:          Are there any gaps higher than $500?

Joe:          No.

Me:          OK, so on that basis I am reasonably confident your anaesthetists are using the “known gap” schemes of the private health insurers. It’s pretty common. We use it for most of our anaesthetists too.

Joe:          What’s a known gap scheme?

Me:          It’s where they are allowed to charge an extra amount over the no-gap amount, which is usually, but not always, capped at $500.

Joe:          I don’t get it. He’s charging a gap of about $200 on an item 17610 that’s on all the invoices.

Me:          Yep, that’s the pre-anaesthetic consultation item.

Joe:          But he’s charging up to $250 for it. What’s the Medicare rebate for it do you know?

Me:          Let me check that for you… $32.25

Joe:          What! The Medicare fee is 32 bucks and he’s charging $250!!

Me:          No, he’s probably not doing that, and it’s not the “Medicare fee”, that’s a bit higher, it’s $43, but the 75 percent inpatient rebate is currently $32.25.

Joe:          These are not inpatients ,they are outpatients. They are day-only patients who don’t stay overnight.

Me:          You admit them to your facility and claim against their private health insurance for the beds and operating theatre fees, right?

Joe:          Yes.

Me:          So that makes them inpatients for Medicare claiming purposes, and the inpatient rebate of $32.25 applies. But the thing is, he can charge up to an extra $500 under the known-gap schemes, but where he actually puts that amount on the invoice is really a separate issue. Some providers just dump it on one item number, although it really should be spread across all of the item numbers on the claim. He is obviously adding the patient ‘known-gap’ to the item 17610 and there’s nothing inherently wrong with that. Known gap claiming is impossibly difficult to administer and he actually could charge more, up to $500, but he’s not; the gaps you have described are about half what he could charge. But that aside, there must be at least two other item numbers on the invoices, one starting with 20 and another starting with 23. Can you see them? There could also be others.

Joe:          Yes, every invoice has an item starting with 20 and another starting with 23. I can’t see any others.

Me:          OK. Those are the usual anaesthetic items and appropriate for his work. Every anaesthetic claim requires a minimum of two item numbers and most have three.

Joe:          But I don’t understand why every gap is a different amount. There is no consistent approach that I can see. Does he just make it up as he goes? Every invoice has a different gap amount even for the same procedure with exactly the same Medicare item numbers on the bill.

Me:          Oh that’s because he would be charging in units. Anaesthetists charge in units, unlike any other specialist. It’s also because every private health fund has different fees for the same item number.

Joe:          This is just getting more and more ridiculous. So, how many units is item 17610?

Me:          Well that’s a good question. It’s a bit of a weird item because it has no unit value under the Medicare Benefits Schedule, but the Australasian Society of Anaesthetists has decided it is two units, so there’s sort of this convention that we all attribute a two unit value to it.

Joe:          (expletive) Is that even legal?

Me:          Yes. Doctors can charge whatever they like. It’s in the Constitution. If they were bulk billing or using the no-gap scheme, the question of units would not arise because item 17610 would just be paid at a flat rate, but for the purposes of deciding how much to charge for that item outside of those arrangements, they can, in theory, allocate as many units as they want. But two is the convention.

Joe:          (audible sigh) So what do the health funds pay for item 17610?

Me:          Let me have a quick look for you… BUPA currently pays $74.40, Medibank Private is $71.05, R&T and the other Alliance funds are $69, HCF is $73 for known-gap doctors and $90.30 for no-gap doctors. I know that’s pretty weird, one fund having two different rates for the same item, but let me tell you, it gets weirder, one fund has three! Anyway, do you want me to go on? There’s more than 30 rates here on our system for that item.

Joe:          No. I’m exhausted.

Me:          Sorry. I’m not explaining it very well.

Joe:          (long pause) Does he get the $32 from Medicare plus the $70 from the fund?

Me:          No, the $32 from Medicare is included in the amount the fund pays. But look, what I think he is doing is this: He has set a flat unit rate for his work, most anaesthetists do that. I don’t know what it is, but let’s say he has decided he wants to be paid $60 per unit for every anaesthetic he administers. Now let’s say the total unit value of the three items on one of his claims comes to 8 units. He therefore wants to be paid $480 in total for that anaesthetic, and that fits within the rules of the known gap schemes. To do the bill for him you sort of have to work backwards from that number. If the total amount the fund pays for the three items is say $280, and remember it will be different for every fund, he has a balance of $200, and he’s adding that to the item 17610 because it’s just easier. Ideally, he should spread that amount across the three items, but it makes no difference to the gap the patient will pay. So he’s not actually charging $250 for item 17610 if you know what I mean. It’s for the whole episode of care. Does that make sense?

Joe:          I think so. But the patients say they didn’t know.

Me:          Ah, well, that’s a separate and very important issue, because when doctors use the known gap schemes, informed financial consent becomes a legal obligation, unless the anaesthetic was an emergency and there wasn’t time to obtain it. But given he’s working within an anaesthetic group I would be very surprised if they are not obtaining informed financial consent for him. Most groups are pretty good at that, but you’ll have to check with him.

Joe:          I will, and none of his cases are emergencies. They are all elective, non-urgent procedures.

Me:          Would you like me to email you a link to the relevant section of the legislation that deals with informed financial consent? It might be useful for you to have at hand while you’re speaking with him.

Joe:          That would be great, thanks.

We left it there and I wished Joe luck. I didn’t like his chances getting the anaesthetist to agree to repay the patients, because there was just no reason for him to do that. The anaesthetist hadn’t done anything wrong, he had claimed within the parameters of the law and the patients had paid his gap fees without complaint (at least without complaining directly to him). It was all done and dusted as far as the anaesthetist was concerned, although there was a question left hanging about whether informed financial consent had been properly obtained.

Standard fees versus standard gaps

That aside, what was interesting was that, irrespective of whether you agree with the OOPs charged by this anaesthetist or not, the fact is that he was doing exactly what consumers are currently demanding – setting a standard fee for his work. But because of the myriad different ways the private health insurers operate their gap cover schemes, his consistent rate of $60 per unit created inconsistent gaps for his patients.

In contrast, Dr Michael Gannon’s earlier comment suggests that he chooses to manage his fees the other way, which delivers consistent gaps for his patients, but not a consistent fee for himself.

Medical billing is a profoundly complex area of law and becoming more so all the time. In 2014 I raised this area of medical billing complexity in a published academic article which included a table of more than 30 different health fund and Medicare fees and rules for a single, commonly used, specialist Medicare item number – yes one Medicare item, more than 30 fees – plus multiple different rules and penalties.

Reviewing the article now, I could easily expand the table considerably, because even more rules and fees have been added to the medical billing labyrinth since the article was published.

There is an extremely low level of legal literacy in the medical billing space, including by those tasked with reform. Doctors don’t learn it; neither do hospital CEOs or academics or government representatives, and consumers therefore have little hope of understanding their medical bills or OOPs.

It is a gaping reform hole that needs to be addressed if we are serious about modernising a sustainable Medicare for future generations and conquering OOPs.

Until then we will have to work with what we have and accept that if medical specialists choose to have a fixed fee, we will pay multiple different gaps for the same service.

Or, if they prefer to ensure their patients all pay the same gap, then they will have to advertise many different fees for the same service.

We will have to decide which we want, because currently, it is not possible to have both.

• Margaret Faux is a lawyer, the founder and CEO of one of the largest medical billing companies in Australia, a registered nurse, and a research scholar at the University of Technology Sydney. Follow on Twitter: @MargaretFaux.

• See the previous articles in the #OutOfPocket series.

(The feature image was sourced via Flickr: https://www.flickr.com/photos/jonavi/37509663536/in/photolist-Z9AQ9Q-5gQh6y-ebiruJ-5cYgUZ-5gffLY-4cgEs4-bjZGiU-6d7shE-8BNRhc-6me29b-5herFk-eJyUM2-6chpd-ot7ktg-8HqcT8-4uHBL7-XWMzGw-8gcvLN-5GjtGq-fpn5Jz-F9aau9-8Yvfza-FsccWo-XKWLN3-rPRz8n-aDLesK-cppEf9-jBC1ny-v8ofLS-dV4bDi-Z2TkVJ-qoenn1-pRjs6C-JEeqx-buiXTi-KGWup-6fLtnh-9JsA7i-XKWLvu-MajpH-4sbXH4-2Hrz1B-K4uGCf-6bvjNs-7Swvfb-NygkKW-Evz4fB-WKee9J-EcFbuD-GbMPt2)

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