By Tim Bonfield
The Cincinnati Enquirer
A widow loses her husband to an unexpected infection, then gets hassled for months about the bills.
A woman spends three months untangling the red tape after her husband's former employer switches health insurers.
See the full results of the poll, share your thoughts and read the first four parts of this series at Cincinnati.Com. Keyword: your health
And thousands of Greater Cincinnati and Northern Kentucky residents get calls from bill collectors every month, sometimes every week, because hospitals, doctors and insurers can't seem to agree on who owes what.
An Enquirer survey conducted in January shows that rising costs rank as the area's No. 1 health-care concern. But even as people complain about costs, many also are asking, "Why can't they get the paperwork straight?"
Red-tape complications such as coverage denials, referral requirements and unintelligible billing statements rank just after rising costs as the biggest health-care aggravations that people face. These frustrations were widely reported even though in most cases, people say they're satisfied with how their bills are handled.
Just ask Rita Adams, Patricia Eschenbach, Thomas Dobbinsor Sharon Braunstein.
Rita Adams from Florence, Ky. has first-hand experience with the difficulties a person can encounter when dealing with hospitals, insurance companies and red tape clogging the health care system.
(Michael E. Keating photo)
Last February, Florence resident Rita Adams wound up in the hospital with pneumonia just a few weeks after her husband's employer switched insurance carriers. The new carrier denied coverage - because the company sent out a card with an incorrect membership number.
"My number wasn't in the system, so I wasn't there (in the hospital), according to them. We were getting bills left and right from the hospital and the doctors," Adams says. "After three months of calls, we finally got to somebody who knew what they were doing. It was May before we finally got things straightened out."
Burlington, Ky., resident Patricia Eschenbach says billing clashes only added to her grief after her husband died in September after developing an infection during a hospital stay.
"He was only supposed to be there three days. It was 20-something days. We were still getting bills three or four months after he died," he says.
The health plan ultimately paid for almost all the costs, more than $260,000. But payments to the hospital were slow and sometimes disputed by the insurer. When that happened, the hospital sent unpaid portions to Eschenbach.
"I had to keep calling back and forth between the hospital and the insurance company," she says. "It kept going in circles."
Fairfield resident Thomas Dobbins says he spent weeks last year making calls back and forth between a hospital and an insurance company to find out why only part of a surgery for his wife's carpal tunnel syndrome was covered.
"You never talk to the same person twice," he says. "It's so complex, so convoluted, people don't know which way is up."
Deerfield Township resident Sharon Braunstein says she spent more than four months straightening out red tape after she switched insurance carriers.
"Somehow, they messed up my records. They tried to say I had more than one insurance company. They kept sending me denials. In the meantime, doctors and hospitals kept sending me bills. I had a terrible time with all the rigmarole."
Even residents who haven't been stung by a billing dispute wonder how much of rising costs are linked to the computers and people and paperwork involved in collecting the bills.
"These expenditures do not benefit our health care at all, but they are included in the costs," Springdale resident John Myers says.
100,000 calls a year
On the fourth floor of the former Bethesda Oak Hospital in Avondale, 95 employees process 600,000 medical bills a year that flow from Good Samaritan and Bethesda North hospitals and assorted outpatient services that make up the TriHealth group.
The Greater Cincinnati Health Council is working with several other groups to develop a voluntary set of patient billing guidelines to cut red tape and ensure that people are treated with respect. Meetings on the guidelines began in January, and a draft version was circulated in early May. A final version could be complete in July, says Lynn Olman, health council president.
The draft includes more than 30 principles and guidelines. Hospital officials say the standards would put into writing what they already do. But consumer advocates say things would change significantly if hospitals consistently followed these standards. Among them:
"All financial assistance applicants should be treated with dignity, respect and with cultural sensitivity. Free interpretation and translation services should be made available as necessary."
"All patients regardless of income level or payment status (i.e. insured, Medicare, self pay) will receive access to the same information regarding services and charges."
"Hospitals should ensure that patient financial services personnel and financial counselors are fully trained on the hospital's financial assistance policies and can communicate those policies clearly to patients. Receptionists and switchboard personnel should be able to direct callers to hospital staff trained to provide financial assistance."
"Legal action, including the garnishing of wages, may be taken by the hospital only when there is sufficient evidence that the patient or responsible party has the income and/or assets to meet his or her obligation."
"Hospitals will not force the sale or foreclosure of a patient's primary residence to pay an outstanding medical bill."
Seven people field more than 100,000 phone calls a year - about seven calls a person each hour - seeking answers to billing questions. Four people spend their days handling patient refunds - yes, repaying people who paid too much, says Todd Cole, director of patient accounting.
At the former Jewish Hospital in Avondale, workers occupy 200 cubicles in the vast patient accounting division of the Health Alliance of Greater Cincinnati, which includes six area hospitals, several outpatient centers and a large physician group.
The Health Alliance processes bills for more than 1 million hospital visits a year, chief financial officer Ron Longsays.
When you're talking numbers of that scale, health-care billing can't help but be complicated.
Hospitals deal with more than 100 insurers and government programs, all with their own rules and standards, Long says. Some are easy to work with. Others aren't.
Getting paid also means dealing with the unending complications that hundreds of thousands of people present: Address changes, health plan changes, illiteracy, foreign languages, homelessness, criminals using false names, custody disputes, legal threats, arrogance, rudeness and people unable to communicate because they suffer extreme illnesses and disabilities.
Some people don't have telephones. Many, many more just won't return a call, Long says.
The rising costs of health care make this whole process more complicated - for patients and health providers.
The percentage of money owed to the Health Alliance from patients has grown from 7 percent of total billings to 8 percent in the past year, Long says.
Hospital administrators see this growth as a disturbing sign.
"We are just now starting to see the effects of larger co-payments," Long says. "It hasn't caused a spike in our bad debt yet, but I think the problem is going to get worse before it gets better."
More trouble for the poor
Some patients involved in billing disputes confess that they ignore all but the most serious collection attempts because they are juggling health bills with other overdue debts, says Trey Daly, a lawyer with Legal Aid Society of Cincinnati, an agency that provides low-cost legal services to people with financial problems.
Most of Daly's clients say applying for financial assistance or negotiating payment plans with hospitals is far more difficult than administrators portray. In the past year, his clients have been sued over disputes involving as much as $31,000 and as little as $350.
"These situations can snowball pretty fast," Daly says. "What makes me concerned is that too many people tell me that they were never made aware of what their options were."
Hospitals do have financial counselors who regularly provide information to poor patients. At University Hospital, some counselors show up with clipboards at the patient's bedside to enroll people in assistance programs.
But more often, needy people are seeking outpatient treatment. They go home within hours, often before counselors can meet with them. Once patients leave the hospital, contacting them becomes much harder.
Hospital leaders agree that more can be done to improve the billing process. The Greater Cincinnati Health Council, a trade group for area hospitals and other health organizations, is working with the Legal Aid Society and other community groups on a draft list of more than 30 principals to reduce medical billing disputes.
"Hospitals still have to address the way we connect the process to the patient," TriHealth's Cole says. "It is still a challenge to streamline the billing process. A lot of mistakes get made."
No grocery runs like this
If a grocery store were run like the health-care system, the result would be bizarre.
Imagine a store where the shopper doesn't decide which items go in the grocery cart. Instead, somebody else - the doctor - tells the shopper what to buy.
Then at the cash register, somebody else - the insurance plan - decides which items from the cart will be paid for. Imagine a grocery clerk saying, "Sorry sir, that brand of cheese snacks isn't covered. Your plan only covers the store brand."
Like a grocery store, items on the health services shelf - the surgeries, the X-rays, the pills and blood tests - do have sticker prices. But unlike a grocery store, health shoppers have a hard time finding the prices.
Health-service shoppers standing in the checkout line soon discover that each person in line pays a different price for the same gallon of milk. Prices depend on contract agreements between the store and the insurance plan involved. Prices also vary according to whatever co-payment arrangement employers set up.
And unlike a grocery store, health shoppers learn the actual charges a few weeks after they leave the store, along with whether the bill was fully paid, and how much more they might owe.
"What other kind of business runs this way? Where else do charges mean nothing?" says Chad Wiggins, chief operating officer for Freiberg Orthopedic and Sports Medicine.
Wiggins doesn't propose how, but he says the entire system needs to be simplified. The excessive complexity of the health-care payment system drives up costs for hospitals and doctors, which in turn means less money to provide care, Wiggins says.
"I do get some patient complaints about physicians, but usually, it's about the process," he says. "Whenever there's a dispute between insurers and doctors, it puts the patient in the middle."
Click here for an in-depth look at:
Enquirer poll: Top complaints about health care
How billing works
Medical bills and bankruptcy
(Acrobat PDF file, 388k)
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