First of all, I don’t expect anyone to agree with my viewpoints. I did and still do agree that drz is and will be ultimately responsible for this bill. What I am suggesting is that an appeal to the payer is not the only avenue that could possibly be pursued. I do not interpret drz’s original post to state that DME in general is excluded from his health plan. I only interpret that this particular piece of equipment was excluded. Next, I don’t care why the DME was excluded from the plan. For practical purposes, knowing the type of equipment drz described, there was a much less costly alternative that was likely the Standard of Care treatment. Once again, I am pointing out the ethical (perhaps I didn’t make that clear in my first post) responsibility that health care providers have to be patient advocates, which would include checking coverage if there is any doubt. I am suggesting that drz could research the incident and use that ethical obligation as a tool to potentially convince the provider/s to negotiate the bill. Health care providers are not ignorant of reimbursements for services. Health care providers are not ignorant of cost effective treatments and Standards of Care. Depending on the value one places on $450.00, what I am suggesting is that drz can do is to do his homework and find out how and why he was stuck with this device. Determine if the physician specifically ordered a motorized device or something simpler. If so, ask him why he chose that as opposed to an ice pack. If not, find out who took it upon themselves to provide the more expensive equipment or if was perhaps an ordering mistake. Having spent numerous years on the provider and payer sides, those are both very real possibilities. I would also suggest that drz educate himself about the specific device that was used prior to undertaking any discussion with the providers. The appeal to the payer failed as I expect it would regardless of the reason for the denial, but that does not mean that drz has to throw up his hands and say, “ok I’ll pay the bill” without exhausting every possibility to save money. Even if he did “take delivery of the product” (like it’s a UPS package, give me a break), none of that changes the fact that there was likely a less costly alternative which the provider would know about. I for one would ask the provider/s be accountable for the choice and explain themselves. It may not do one bit of good but providers negotiate disputed bills all the time. Squeaky wheels often do get greased. When does “ultimate responsibility” begin? When someone tells me it should or after I’ve exhausted every possibility I can think of? I know the answer for me and my patients. This isn’t a theory, I use crap just like what has been discussed to negotiate these kinds of disputes on behalf of my clients all the time. Sometimes successfully, sometimes not, but at least I try instead of throwing my hands up and telling my client, “Too bad, it’s your ultimate responsibility” without even exploring their concerns.
One actual example I can give is of a patient with multiple myeloma hospitalized for weeks following a bone marrow transplant. She developed severe spinal pain from bone lesions. The doc recommends a vertebroplasy. Should the patient in that situation think to ask “is that an experimental procedure?” Ethically, I don’t think so. As a matter of fact, she should have (since the patient is always responsible. Why let little things like extreme pain, exhaustion, fear, depression, and a terminal diagnosis interfere with your thought processes). Did the doctor know it was an experimental procedure? You bet. Did the doctor know an experimental procedure is likely to be denied coverage? You bet. Did he inform the patient that the procedure is considered experimental? No. (Hummm, “informed consent”.) Should he morally and ethically have checked coverage? You bet. Did he? No. Should the UMD of the facility have checked, morally and ethically? You bet. Were they required to? No. Was the procedure paid for? No. Was the patient responsible for the payment? Yes. Will you find vertebroplasty listed specifically in a plan doc? Not likely. Were there Standard of Care alternatives? Absolutely. The adverse determination was appealed and denied. It was secondarily appealed and denied. It was sent to independent physician review and the denial was upheld because all current medical literature at the time did not support the procedure as a Standard of Care. Do doctors and facilities know what the Standards of Care are? You bet. Do patients? No. Providers have a moral and ethical responsibility to their patients to provide Standards of Care and be patient advocates in all areas, including costs. The providers in the above scenario expected the procedure to be undetectable in a catastrophic claim of over $600,000.00. They were wrong and the patient almost paid. Fortunately for this patient, after all the appeals were done we were successful at having the facility forgive the charges—considerably more than $450.00. We didn't have to, we could have let her take ultimate responsibility by paying the bill. This patient was ultimately responsible yet she never paid a dime for the experimental procedure. She took responsibility, exhausted her appeals process, and enlisted the aid of someone who could help her. I have seen reduction or forgiveness of patient responsibility debts for everything from experimental services, Usual Customary Reasonable charges, timely filing issues and various other services. I refuse to let my clients incur these charges if I can help it simply because the provider has no legal or even contractual obligation to check coverage and / or does not provide the patient enough information to make an educated decision.
