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Updated: Friday, 22 Feb 2013, 10:13 AM EST
Published : Thursday, 21 Feb 2013, 10:41 PM EST
GREENWOOD, Ind. (WISH) - A Greenwood doctor is under fire after he admitted he charged a patient more money for, among other complaints, “incessant whining.” I-Team 8 found elements of discretionary billing could affect other patients who might not ever know it.
THE “INSIDE RHEUM”
The comments came in a blog post written by Dr. Larry Greenbaum, a board certified Rheumatologist for the last 24 years who is paid to write a twice-monthly column on his practice in Greenwood.
He calls it “Inside Rheum.”
"If your practice is like mine, you probably don't bill for consult level 5 very often," Greenbaum writes in one of his latest posts. "That's the most expensive level of care on our office super-bill. I usually reserve it for patients with huge volumes of records, patients who take an inordinate amount of time, or patients who annoy me in some other extraordinary fashion."
One of those "annoying" patients, Greenbaum writes, was a 75-year-old who recently came in for an initial consultation.
By Greenbaum's account, the visit didn't go very well.
"I charged him level 5," he writes in the post, "for taking so much of my time, for bad-mouthing his previous doctors, and for incessant whining."
Greenbaum goes on to describe the visit in detail, including an anecdote about how the patient admitted to kissing his neurologist’s hand. He writes that the patient “didn’t seem demented or hateful, just weird."
"I wasn't the least bit insulted," he finishes.
But, others are.
“It rubs me the wrong way,” said Delana Gifford, a former patient of Greenbaum's, who says she had problems with Greenbaum’s care and recently found another doctor.
When a friend sent her a link to the post, Gifford says she was outraged.
“I was shocked. I read what he said and I was horrified. To reserve the highest fee because someone annoyed you on that particular day? That's reprehensible,” Gifford said.
I-Team 8 consulted with several medical billing experts. All said the post likely doesn’t rise to the level of “illegal billing.”
“[The post] is pretty brazen. That's pretty bold. But, it's going to be very hard to prove that. You do have to have intent [of billing abuse] outlined, and it has to be well documented. And, that's going to be hard,” said patient advocate Jared Ferguson, Founder of Patient Advocacy of Indiana.
Still, Ferguson says billing “abuse” is a common complaint.
“They are obviously going to try to make sure they maximize their ability to get what they have owed to them. And, sometimes that effort to ensure that they maximize that does lead to this discrepancy where they may or are starting to tier toward that over-billing and abusing that billing system to try to get more from insurance providers. That does probably happen. But, I would say you're going to also get the argument, especially from the hospital side, that they also do a lot of things that they don't bill for,” Ferguson said.
One of the more common complaints revolves around what the medical billing industry calls "up-coding."
“Visits are based on the complexity of the patient,” said Deborah Grider, a senior manager at Blue & Co., a medical billing and coding company in Indianapolis.
“We have what we call level 1 through level 5. Level 1 patients have a simple problem with a simple solution. They're coming in for a cold, a runny nose or something simple. And the doctor tells them to take something over the counter or does very minimal intervention with that patient. Your level 5 patients are ones that are very complex. They might have hemophilia or cancer or cardiac disease, and the management options are very complex,” Grider said.
“There's that opportunity there in those arenas where there could be bills for things that weren't provided,” Ferguson said. “But, I would again go back to say that most providers aren't going after that. It's too much risk for them.”
A “TONGUE IN CHEEK” POST
I-Team 8 went to Greenbaum's office to get his side of the story. He agreed to sit down for an interview, where he admitted he wrote the post. At first, he called the writing “tongue in cheek.”
“It was meant to be funny. It was a funny visit. It was certainly never my intention to insult anybody,” he said.
But, Greenbaum also called the patient’s bill “justified,” and he isn't backing down on the reasons behind it.
“If you read on to the second paragraph, you see that I spend an hour with the patient, which is twice the length of time I normally spend with a patient who is sent for consultation. So, even though I may have taken a little bit too much glee in checking off level number 5, it really was justified since I spent an hour with him,” Greenbaum said.
Asked whether he thought it was appropriate to bill a patient because of “annoyance,” Greenbaum paused.
“He didn't annoy me that much,” he responded. “I have lots of patients who are far more annoying. It's not used as a billing method. It is used as a rhetorical flourish.”
But, that flourish sparked online outrage.
Medical based blogs linked to the post have garnered hundreds of comments. One appears under the headline "worst doc of the year."
Asked if those commenting were making too much of the post, Greenbaum nodded.
“I'm afraid so,” he said.
Gifford, the former patient, disagrees.
“When someone comes into a doctor's office, they're there for a valid reason. And, they want their concerns to be heard, not to be made fun of,” she said.
Those posting complaints online also raised concerns that Greenbaum had divulged private patient information. A federal law known as HIPAA prohibits doctors from using information "that identifies an individual or could be used to identify an individual."
In his post, Greenbaum talks about the man's medications, dosages, and identifies several specific chronic medical problems.
“Once you have three identifiers, you start to run into a gray area,” Ferguson said. “If you were that person's neighbor, you might start to wonder. He’s running a very fine line.”
But, Greenbaum says he didn't divulge anything that isn't allowed.
"His name is not there. I don't see how anyone could possibly identify the patient on the basis of [the medication he was taking],” he told I-Team 8.
Greenbaum says he stands behind what he wrote.
“I'm sorry if anyone was insulted. No offense was intended. But, I’ve not [done anything wrong],” he said.
She says she filed a complaint with Indiana’s Medical Licensing Board and the Indiana Attorney General's Consumer Complaints Division.
A spokesperson for the agencies told I-Team 8 that the office can't comment on specific complaints. But, she did confirm no cases have been settled against Greenbaum.
I-Team 8 also found no disciplinary action on Greenbaum's record.
His license remains listed as “active.”
Ferguson says most patients would never know if they had been billed incorrectly.
"From the patient perspective, it's almost impossible unless you have medical training, or medical coding specialty,” he said.
Those codes are supposed to tell insurance carriers what services a doctor provided. Medical bills are supposed to reflect those services.
“They will take the condition they have written in your medical record. They will write down what services they provided, why they provided them, what's wrong with you. Those will be translated into codes. Some procedures can be based on time, like counseling and coordination of care. Critical care services are time based services,” Grider said.
In general, the sicker a patient is, the higher their billing level becomes, Grider said.
“I always tell physicians to reserve the level 5 visits for the very sick patients [where] their life is at risk. If they don't intervene, there's some risk to life. That's what the level 5 is there for. Just for an annoyance or because they spent an hour with the patient doesn't quantify for that high level of service,” she said.
Most private insurers have anti-fraud divisions, who look for patterns of high level billing. The federal government is supposed to do the same.
But, a report from the non-partisan Government Accountability Office (GAO) released in December showed Medicare and Medicaid made more than $64 billion in “bad payments” in 2011. At least 20 percent of that was due to over-billing.
And, to make things even more confusing, medical bills are about to get a lot more complicated.
A new national billing system called “ICD 10” is set to take effect in 2014. Experts are already predicting severe strain on the system when it does.
I-Team 8 asked the Washington D.C. based Patient Advocate Foundation for tips on protection from over-billing:
1) Speak to your providers and doctors before services (if possible) to get an estimate of charges involved. This will help you get a sense of what to expect in the paperwork following your treatment/healthcare.
2) The patient should always match up their Explanation of Benefits performed on each date of service following medical care to the Billing Statement to ensure they match and both are complete. The explanation of benefits is issued by your insurance company and will most likely be the first paperwork to come in following medical care. This will be followed by the individual billing statements by each provider that was involved in your care. [sometimes patients are surprised just how many providers participated -for example, you may see individual bills for lab work, specialist service, facility care, radiology, etc] In addition to ensuring these statements and bills match, many times the patient will to want to take their investigation a step further and à
3) Ask your provider's office for a detail billing, also called a itemized statement on all charges for that service date. Some providers always provide a detailed list and some will simply show an all inclusive total rate on the bill. Once you have a detailed bill, any questions regarding specific coverage for these charges can be addressed by the insurance company. Patients can certainly ask questions of explanation to the providers office as well.
4) Most importantly - go with your gut! If something feels weird or strikes you as strange on your bills, take the time to investigate! Mistakes impact not only the official record keeping of your medical treatment, procedures and health, but they can also dramatically impact the patient's out of pocket costs.
5) Always keeping good records and folders for all medical bills. Sorting your explanation of benefits organized by date of service and by providers is important. Records should also include date, time and content logs of all communication and advice given by relevant parties.
6) If you are not making headway with your provider's billing office or your insurance company, consider involving an advocate on your behalf. Many hospitals have on-site advocates or social workers to assist patients, and there are a number of trusted industry experts and nonprofits dedicated to helping patients navigate the healthcare world. An advocate is trained and experienced in navigating these healthcare systems, and will have a better understanding of the language and complexity involved. Advocates can be a great resource for a patient who is dealing with coding and billing concerns.
To read Dr. Greenbaum’s blog post click here.