HCA Accused of Billing Fraud

[Birdstrike]

Many of you likely work in an HCA-owned Emergency Departments. Many of the accusations in this suit involve ED related matters. Anyone care to comment?

HCA accused of billing fraud: 3 things to know. A former nurse at Regional Medical Center in San Jose, Calif., filed a federal lawsuit alleging the hospital and its owner, Nashville, Tenn.-based HCA Healthcare, submitted false claims to Medicare.

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[southerndoc]

Wow. If this is upheld that hospitals cannot bill for inpatient care while patients are boarding in the ED, then that will drastically change hospital reimbursement and likely stimulate a major push to expand hospitals or increase staffing (as frequently "no beds" usually means 50 beds that cannot be staffed due to no filled position).

If I read this correctly, a nurse filed the federal lawsuit. I'm assuming if she wins she will have to forfeit the money to CMS, but will be rewarded about 30% for her efforts in whatever money is recovered.

 

[deleted547339]

HCA sent a $3,000 bill to someone I know for 3 stitches by an NP - and I’m pretty sure they had Blue Cross. I’m sure anything they are accused of is not only true, but the tip of the iceberg.

 

[MechEDoc]

I've never worked at HCA facility that I would like to receive care at. I now work at a hospital where I would seek care if needed. I hope HCA reaps something commensurate with what they've done to others.

 

[southerndoc]

HCA sent a $3,000 bill to someone I know for 3 stitches by an NP - and I’m pretty sure they had Blue Cross. I’m sure anything they are accused of is not only true, but the tip of the iceberg.

That's not an unheard of ER bill for a simple laceration.

My daughter's bill for a partially amputated toe was $17,000. This included procedural sedation and a plastic surgeon coming to reattach it.

 

[Tenk]

 

[deleted547339]

That's not an unheard of ER bill for a simple laceration.

My daughter's bill for a partially amputated toe was $17,000. This included procedural sedation and a plastic surgeon coming to reattach it.

This was a simple lac, not seen by an MD, 3 stitches. And they have great insurance. That’s $1,000/stitch out of pocket. If that’s not unheard of, I don’t know what is.

 

[VA Hopeful Dr]

This was a simple lac, not seen by an MD, 3 stitches. And they have great insurance. That’s $1,000/stitch out of pocket. If that’s not unheard of, I don’t know what is.

...that's now how lacerations are billed.

Also we all know that everyone bills insurance for way more than what the insurance will allow. What did BC actually allow in your friend's case and what did your friend up end actually paying?

 

[Dr Mantis Toboggan]

My guess is EmCare was out of network. They are infamous for intentionally not going in network and hitting people for crazy bills.

 

[GonnaBeADoc2222]

Probably the impetus for all these states to disallow balance billing now

 

[namethatsmell]

From what I've heard this is more about typical BS upcoding rather than boarding per se.

Wouldn't it be nice if it forced HCA to have to change their business structure?

Wouldn't it be great if this sent shock-waves through for-profit hospital chains and CMG land?

Perhaps this will force people to realize that the vast majority of big for-profit health corps are in direct conflict with their own best interests and real change will finally come...

Or let's be realistic: this chapter of HCA drama won't cause big changes in the EM landscape. Not enough people are going to care. The level of separation the insurance companies introduce between patients and the CMGs/hospitals make this quite impersonal for the likes of Andy Average and Sally Swell. Maybe a few people will roar loudly but most won't bat an eye away from instagram, candy crush, and GOT long enough to care (I can't fault them for the last one). HCA will get fined and a slap on the wrists.

I hope I'm wrong, but I'm not holding my breath.

 

[deleted547339]

...that's now how lacerations are billed.

Also we all know that everyone bills insurance for way more than what the insurance will allow. What did BC actually allow in your friend's case and what did your friend up end actually paying?

That was what they were charged after insurance....BC paid some 4 figure number and they were left with >3k individually.

 

[deleted547339]

My guess is EmCare was out of network. They are infamous for intentionally not going in network and hitting people for crazy bills.

That’s so unethical. How can a major network be out of network for BC/BS? That’s like not taking Medicare.

 

[southerndoc]

That’s so unethical. How can a major network be out of network for BC/BS? That’s like not taking Medicare.

Because BC/BS refused to negotiate with the doc group. Some insurance companies want to pay far less than the FAIR Health Database.

 

[southerndoc]

Probably the impetus for all these states to disallow balance billing now

I'm on board with this as long as they tie it to the FAIR health database.

 

[southerndoc]

This was a simple lac, not seen by an MD, 3 stitches. And they have great insurance. That’s $1,000/stitch out of pocket. If that’s not unheard of, I don’t know what is.

Is this the MD bill or facility bill? A standard facility charge is about $1500 just for walking into the ER.

 

[Dr Mantis Toboggan]

Is this the MD bill or facility bill? A standard facility charge is about $1500 just for walking into the ER.

Yup. Although I have personally seen some pretty egregious provider charges from Envision (2k for a corneal abrasion seen by a Midlevel).

 

[Brigade4Radiant]

If you get charged this outrageous bills negotiate with the hospital often times you will only be on the hook for a quarter of the payment. A cbc or bmp is often charged 1500 each or an ekg is 600.

 

[RustedFox]

This nonsense is pretty much the second biggest reason that I'm mad at "medicine".

Charge something reasonable, insurers.
Pay what you owe.
Don't be obfuscatory.
Be a "Good Guy Greg".
People won't hate you.

 

[Hamhock]

This nonsense is pretty much the second biggest reason that I'm mad at "medicine".

Charge something reasonable, insurers.
Pay what you owe.
Don't be obfuscatory.
Be a "Good Guy Greg".
People won't hate you.

Sure, except that "self-regulation" doesn't work in most industries (see oil industry, pharma, etc). It surely doesn't work in the "insurance" world.

Of course, regulation from government sends the libritarian/free marketers to the megaphone to yell about "socialism".

Gotta give somewhere.

HH

 

[RustedFox]

Sure, except that "self-regulation" doesn't work in most industries (see oil industry, pharma, etc). It surely doesn't work in the "insurance" world.

Of course, regulation from government sends the libritarian/free marketers to the megaphone to yell about "socialism".

Gotta give somewhere.

HH

Yeah. I hear you; but "gotta give" shouldn't be "3000 dollars for three sutures".
Some sanity needs to prevail here.

 

[deleted109597]

Because BC/BS refused to negotiate with the doc group. Some insurance companies want to pay far less than the FAIR Health Database.

Yes, the number of people, much less physicians, that continue to be blind to this is astounding.

 

[deleted109597]

Also, for those of you not aware, most insurance companies pay the same for a visit at an ER whether you were seen by a doc or an NP. If that isn't maddening I don't know what is.

 

[RustedFox]

Also, for those of you not aware, most insurance companies pay the same for a visit at an ER whether you were seen by a doc or an NP. If that isn't maddening I don't know what is.

Don't get me started on the NP (or MLP) thing again. I am so happy on my beta-blocker.

 

[TooMuchResearch]

If you get charged this outrageous bills negotiate with the hospital often times you will only be on the hook for a quarter of the payment. A cbc or bmp is often charged 1500 each or an ekg is 600.

Whoa, I've seen our charges, nowhere near that, and we do alright.

 

[EctopicFetus]

Many of you likely work in an HCA-owned Emergency Departments. Many of the accusations in this suit involve ED related matters. Anyone care to comment?

HCA accused of billing fraud: 3 things to know. A former nurse at Regional Medical Center in San Jose, Calif., filed a federal lawsuit alleging the hospital and its owner, Nashville, Tenn.-based HCA Healthcare, submitted false claims to Medicare.

YOu should have added "again" to your title.

 

[Birdstrike]

YOu should have added "again" to your title.

Correct. Thank you for the reminder. For the uninitiated:

LARGEST HEALTH CARE FRAUD CASE IN U.S. HISTORY SETTLED
HCA INVESTIGATION NETS RECORD TOTAL OF $1.7 BILLION

"Previously, on December 14, 2000, HCA subsidiaries pled guilty to substantial criminal conduct and paid more than $840 million in criminal fines, civil restitution and penalties. Combined with today's separate administrative settlement with the Centers for Medicare & Medicaid Services (CMS), under which HCA will pay an additional $250 million to resolve overpayment claims arising from certain of its cost reporting practices, the government will have recovered $1.7 billion from HCA, by far the largest recovery ever reached by the government in a health care fraud investigation."

 

[kamilo6]

Hi. Can someone help?
With potential false claims as a W-2 versus true 1099 getting paid a day rate:
which status is the rendering doctor “innocent” from error made by outside billing company where billing claims etc not available for review (seriously no access due to clinic ownership set up).
Conflicting information from 2 attorneys & “the internet”.
(If wrong thread let me know).
Thanks.

 

[Birdstrike]

Hi. Can someone help?
With potential false claims as a W-2 versus true 1099 getting paid a day rate:
which status is the rendering doctor “innocent” from error made by outside billing company where billing claims etc not available for review (seriously no access due to clinic ownership set up).
Conflicting information from 2 attorneys & “the internet”.
(If wrong thread let me know).
Thanks.

If you have a legal question so difficult that "the internet" can't agree and even attorney's can't agree, I'm pretty sure asking "the internet" again is not going to clarify the situation. For legal advice (which is what you're seeking) consult a third attorney in the real world, not on the internet, to break the tie.

 

[GeneralVeers]

Hi. Can someone help?
With potential false claims as a W-2 versus true 1099 getting paid a day rate:
which status is the rendering doctor “innocent” from error made by outside billing company where billing claims etc not available for review (seriously no access due to clinic ownership set up).
Conflicting information from 2 attorneys & “the internet”.
(If wrong thread let me know).
Thanks.

Generally when working with a CMG you sign a form that gives the CMG exclusive right to bill in your name. You are not being paid by the government or insurers directly, rather than income is passing through the CMG, via their billing company, then the CMG is paying you what they think you are worth. Any fraudulent billing would fall on the CMG rather than the individual doctor.

 

[GeneralVeers]

Sure, except that "self-regulation" doesn't work in most industries (see oil industry, pharma, etc). It surely doesn't work in the "insurance" world.

Of course, regulation from government sends the libritarian/free marketers to the megaphone to yell about "socialism".

Gotta give somewhere.

HH

I've always said that what would work is up-front pricing both on the website, and in the ED itself. This pricing wouldn't be posted in the ED, as it could be construed as an EMTALA violation, but it would be easily available to any patient who walks in BEFORE they are checked in. The pricing would list out-of-network and self-pay costs for the visit, common lab tests, and common radiologic studies. Mandatory availability of these prices would force hospitals to adjust their prices to a reasonable level as it would create competition.

A big part of the problem is the patients themselves. Most people I talk to don't know what their insurance covers, don't bother to research if the facility they are going to is in-network, and don't know what percentage is their cost-sharing portion.

 

[GonnaBeADoc2222]

I've always said that what would work is up-front pricing both on the website, and in the ED itself. This pricing wouldn't be posted in the ED, as it could be construed as an EMTALA violation, but it would be easily available to any patient who walks in BEFORE they are checked in. The pricing would list out-of-network and self-pay costs for the visit, common lab tests, and common radiologic studies. Mandatory availability of these prices would force hospitals to adjust their prices to a reasonable level as it would create competition.

A big part of the problem is the patients themselves. Most people I talk to don't know what their insurance covers, don't bother to research if the facility they are going to is in-network, and don't know what percentage is their cost-sharing portion.

Some people actually DO do their homework. They verify that the hospital that they want to go to is in network, The problem arises when the ER group is out of network, the radiology group is out of network, and the Anesthesiologist who participates in their appendectomy is also out of network. Patients don't necessarily realize that all these docs may not be hospital employed, and when things are emergent or semi-emergent, this is completely unfair to the patient.

 

[VA Hopeful Dr]

Some people actually DO do their homework. They verify that the hospital that they want to go to is in network, The problem arises when the ER group is out of network, the radiology group is out of network, and the Anesthesiologist who participates in their appendectomy is also out of network. Patients don't necessarily realize that all these docs may not be hospital employed, and when things are emergent or semi-emergent, this is completely unfair to the patient.

Yep. I know how my insurance works quite well (admittedly as a physician I have a better working understanding of this than most to begin with), but even in the hospital that I work for I have no idea if the pathologists or radiologists are employed or part of a PP group and if the latter whether or not they are in network.

 

[thegenius]

HCA sent a $3,000 bill to someone I know for 3 stitches by an NP - and I’m pretty sure they had Blue Cross. I’m sure anything they are accused of is not only true, but the tip of the iceberg.

This is everywhere. Every hospital charges an exorbitant amount of money for something like this. The actual, real cost of putting in 3 stitches should be 100 bucks.

This is a perfect example of the single biggest problem with healthcare billing. People aren't paying for their services, a third party is. People / patients have basically no incentive to understand the costs of health care if they aren't paying out of pocket.

 

[thegenius]

Yup. Although I have personally seen some pretty egregious provider charges from Envision (2k for a corneal abrasion seen by a Midlevel).

our health care system is so f'ed up.

One of the big reasons why i wouldn't mind being a Kaiser doc is you get, basically, free health care for the rest of your life. That has to add up to hundreds of thousands of dollar savings over your lifetime.

(provided Kaiser doesn't change their compensation package to docs).

 

[thegenius]

This nonsense is pretty much the second biggest reason that I'm mad at "medicine".

What is the first?

 

[deleted547339]

This is everywhere. Every hospital charges an exorbitant amount of money for something like this. The actual, real cost of putting in 3 stitches should be 100 bucks.

This is a perfect example of the single biggest problem with healthcare billing. People aren't paying for their services, a third party is. People / patients have basically no incentive to understand the costs of health care if they aren't paying out of pocket.

Uh, no. When I took my kid to the ER, I got a bill for $100 copay on a 500ish dollar bill. The ER charged a reasonable fee. When my brother went, he got hit with a 10kish bill, 3k of which he was charged.

All places don’t do this.

 

[RustedFox]

What is the first?

The patient.

 

[Backpack234]

Correct. Thank you for the reminder. For the uninitiated:

LARGEST HEALTH CARE FRAUD CASE IN U.S. HISTORY SETTLED
HCA INVESTIGATION NETS RECORD TOTAL OF $1.7 BILLION

"Previously, on December 14, 2000, HCA subsidiaries pled guilty to substantial criminal conduct and paid more than $840 million in criminal fines, civil restitution and penalties. Combined with today's separate administrative settlement with the Centers for Medicare & Medicaid Services (CMS), under which HCA will pay an additional $250 million to resolve overpayment claims arising from certain of its cost reporting practices, the government will have recovered $1.7 billion from HCA, by far the largest recovery ever reached by the government in a health care fraud investigation."

Yeah, but this guy became governor of Florida. And he's a senator now. So...lessson learned?

 

[Booze Aldrin]

This was a simple lac, not seen by an MD, 3 stitches. And they have great insurance. That’s $1,000/stitch out of pocket. If that’s not unheard of, I don’t know what is.

Well, I suppose there has to be some way for the hospital to make up for the undocumented farm laborer's 50 day "free" ICU stay and the like. You're not getting that money out of the overclass' Cayman accounts and you're definitely not getting it from the underclass, so the middle class gets to pay $1000 per stitch. Feudalism is back: the elites are the lords, the underclass are the brigands, and the middle class are the serfs getting extorted by both. The only thing preventing the situation from literally going medieval is our reserve currency status, peace be upon it.

 

[deleted547339]

Well, I suppose there has to be some way for the hospital to make up for the undocumented farm laborer's 50 day "free" ICU stay and the like. You're not getting that money out of the overclass' Cayman accounts and you're definitely not getting it from the underclass, so the middle class gets to pay $1000 per stitch. Feudalism is back: the elites are the lords, the underclass are the brigands, and the middle class are the serfs getting extorted by both. The only thing preventing the situation from literally going medieval is our reserve currency status, peace be upon it.

No. I get how medicine works. I attend in an academic ED and ICU. I’m not disillusioned about how this works. What I’m saying is that HCA goes beyond billing a little on the high side to make up for this and crosses well into the realm of fraud.

 

[deleted859535]

Well, I suppose there has to be some way for the hospital to make up for the undocumented farm laborer's 50 day "free" ICU stay and the like. You're not getting that money out of the overclass' Cayman accounts and you're definitely not getting it from the underclass, so the middle class gets to pay $1000 per stitch. Feudalism is back: the elites are the lords, the underclass are the brigands, and the middle class are the serfs getting extorted by both. The only thing preventing the situation from literally going medieval is our reserve currency status, peace be upon it.

What are you smoking that has led you to compare American healthcare to feudalism? Good lord.

 

[The Knife & Gun Club]

What are you smoking that has led you to compare American healthcare to feudalism? Good lord.

He’s some looney 1st year med student. Just block him and move on with your life.

 

[Birdstrike]

Yeah, but this guy became governor of Florida. And he's a senator now

You are correct. Thee Rick Scott.

 

[Birdstrike]

What are you smoking that has led you to compare American healthcare to feudalism? Good lord.

Just one of many trying falsely persuade you that living in the single most prosperous, technologically advanced time in human history is somehow reason to tear it all down and start over.

 

[GeneralVeers]

Just one of many trying falsely persuade you that living in the single most prosperous, technologically advanced time in human history is somehow reason to tear it all down and start over.

Isn't that what Thanos wanted to do?

 

[RoyBasch]

Yeah, but this guy became governor of Florida. And he's a senator now. So...lessson learned?

I remember discussing this with a friend of mine not in healthcare, somehow it came up that Rick Scott perpetrated the biggest medicare fraud in history, and my friend asks, "So whatever happened to that guy? Prison?" I told him: "Nope they made him a senator."

I'm told the commander in chief has plans to make him "health care czar" to help redesign the new american healthcare system 😕

 

[Siggy]

This is everywhere. Every hospital charges an exorbitant amount of money for something like this. The actual, real cost of putting in 3 stitches should be 100 bucks.

This is a perfect example of the single biggest problem with healthcare billing. People aren't paying for their services, a third party is. People / patients have basically no incentive to understand the costs of health care if they aren't paying out of pocket.

Well, that and you're paying for the 5 other people who didn't pay their bill, but that the ED (and connected on-call services) were required to treat without regard to either cost or ability to pay.

 

[GeneralVeers]

I remember discussing this with a friend of mine not in healthcare, somehow it came up that Rick Scott perpetrated the biggest medicare fraud in history, and my friend asks, "So whatever happened to that guy? Prison?" I told him: "Nope they made him a senator."

I'm told the commander in chief has plans to make him "health care czar" to help redesign the new american healthcare system 😕

A corrupt capitalist is still better than the socialist alternative......

 

[deleted109597]

Yeah, the reason the physician groups end up being out of network isn't because they demand exorbitant amounts of money.
Remember, our professional fees are <10% of the total bill, between facility, radiology, pharmacy, lab, etc. The doc gets ~$200 for an insured level 5. They get ~$118 for a Medicare level 5. But then BC/BS comes up with numbers where they agree to pay 80% of medicare rates for pro fees, and the physician groups balk.