People hate Twitter for a lot of good reasons, but undeniably, when people post their crazy medical accounts, it reigns supreme and goes viral. This week, a woman in New York tweeted about her sister's bill, which allegedly included "$40 to cry on."
Camille Johnson@OffbeatLook
My little sister has been struggling a lot lately with a health issue and was finally able to see a doctor. They charged her $40 for crying.
5:41 pm ∙ May 17, 2022
515.709likes66.132You will return
The tweet was similar to another post that went viral last year: a person whose birthmark removal bill included $11 for "brief emotions" the poster assumed was crying. But she got a $2.20 discount.
mosquito@mxmclain
Birthmark Removal: $223 Crying: Extra
8:34 pm ∙ September 28, 2021
192.167likes15.607You will return
The line "Brief Emotion" in the second tweet is short for "brief emotional/behavioral assessment", the same payload as the first tweet, which falls under CPT code 96127. (You can only see the end of the code in the left column. ) The full definition is: “Brief emotional/behavioral assessment (e.g., Depression Inventory, Attention-Deficit/Hyperactivity Disorder [ADHD] Scale), with scoring and documentation, per standardized instrument.” Therefore, none of the patients were chargedTo cry, by itself; They were accused of being screened for depression or other mental health issues. The American Academy of Family Physiciansit saysthat this code should only be used for "purely preventative" tests, not based on signs or symptoms - such as crying in a doctor's office. Hmm!
Let's go back - what the heck are CPT codes? Current codes of procedural terminology (CPT) are crazy medical billing language. They exist to value every imaginable medical procedure and activity, from a physical exam to a circumcision. Providers use these codes to pay payers like insurance companies or Medicare, or you if you don't have insurance.Almost all medical suppliesin the US it's paid using a fee-for-service model that reimburses medical providers for the care they provide based on your activities and explains why you're getting bizarrely specific line items and unfathomable codes on your bill. These codes are extremely useful if you want to dispute a medical bill because you caneasy to discoverhow much Medicare reimburses providers for these billing codes using the physician fee schedule lookup.
Using this tool, we can see that Medicare pays between $4 and $6 for 96127, depending on location.ten times lessthan the patient was charged in the tweet.
The fee-for-service model encourages vendors to find increasingly expensive codes to allocate to their activities, spawning an entire consulting and expertise industry."Maximize revenue" through medical coding.I founda blog poston the Therapy Notes page specifically about using code 96127 to generate revenue:
96127 can be billed up to four times per customer per session. This means you can manage, classify and bill each client for up to four separate instruments each time they join a session. A quick search of reimbursement rates at major insurers shows you could earn an additional $4-$8 per instance of the code. The combination of code 96127 and MIPS payment adjustments, when a Medicare beneficiary comes in for a total of 15 sessions plus one intake, administering four instruments per visit and successfully reporting MIPS data, can increase your revenue for that client at nearly $400! Check with your payers how this code is refunded.
This post appears to encourage therapists to use four separate screening tools for different mental health diagnoses in each session. I'm not a therapist but I ambindepressed, and with each new provider, I welcome the 9-question depression screen like an old friend. I can't imagine how filling each session could make good use of the limited time you have with a therapist - let alone filling three more. If I didn't have ADHD last week, I probably don't have it this week. Such a thing is an obscure art for doctors: if they get it wrong, that's what it means.Upcoding, and it is illegal. When they get it right, it's all about maximizing sales.
Patients can learn many lessons from these two examples of billing madness and this little CPT code.
First, when it comes to medical bills,It is difficult, if not impossible, to know what you will be charged. In the case of the 2021 tweet, the patient reasonably assumed that "brief emotion" meant he was crying. (Not a particularly far-fetched assumption, considering new parents are gettingcalculatedto insure their newborns.) The purpose of the itemized bill is supposed to show what the patient or their insurance is paying. How are you supposed to know how reasonable the charge is when they just say something like "brief excitement" or in this case "doctor be"? We have a very comprehensive (albeit bizarre) system of CPT codes that provide a standardized language for communicating medical information, but invoices are not required to include these codes. There is no standardization of medical bills. I have an account on my desk now for a few months worth of therapy sessions and there are no CPT codes on it. This kind of inconsistency and imprecision makes it difficult for patients to know what they or their insurance is paying for.
This brings me to the second lesson:Pricing transparency rules for hospitals are useless. Anyway, you could imagine this if you spend more than six seconds thinking about how sick patients decide where to seek treatment, even if it's not an emergency, but the way the rules were implemented still makes it less practical to use that data. Hospitals are not required to publish these files in a format that patients can easily read or in a standardized format. I checked out a few hospitals in New York City as that's where this week's tweeter is and it's a nightmare.
New York Presbyterian, one of the largest hospital systems in the city, only provides a .JSON file, which opened up to me like a wall of unreadable text. (There are ways to make them readable, but I honestly don't know how, and no one should need to know that to read their price list.) Northwell Health, meanwhile, has a comparatively useful Chargemaster, though it doesn't have CPT codes; just gibberish descriptors like "BRACHY PLAN C" and "SP BX LUNG MEDIASTINUM SISC". The list price for the brief emotional/behavioral assessment is $75, but it doesn't tell us what they charge for various insurance plans, unlike competing hospital NYU Langone.
NYU has a massive "Chargemaster" with over 48,000 lines. My 18-month-old MacBook Pro could barely open it, but I finally managed to figure out NYU's "list price" for CPT code 96127: a whopping $118, about three times the tweeter's sister and 23 times the price that the Medicare pays. (The list price is made up. It doesn't matter.) The NYU Chargemaster also shows that its prices for various carriers can be found everywhere. Some pay $6. Others pay $45 or $75. The Emblem Essential Plan pays $116, just $2 less than the list price. The "discounted" cash price is $29. Even if you knew how to find that price list, had a computer, and could open and navigate the massive spreadsheet, you have almost no idea that you'll be charged for that review before it arrives, or what they would cost, or whatever your code is. CPT. The price list is useless.
Which brings me to the third lesson:Health care prices are very inconsistent.They usually lead to more questions than answers. Why did the patient pay $11 for wart removal, but the patient in this week's viral tweet paid $40? Why does NYU Langone charge some insurers $6 and others $116 for the exact same thing? The CVS Group, which owns Aetna, isthe biggest insurerupstate New York, and Aetna pays $71 for code 96127 at NYU Langone. Shouldn't their position in the market allow them to negotiate a price 10 times the Medicare cap? There are more than 10,000 CPT codes; With so many different insurance plans, how can hospitals negotiate such different prices for each one? What is literally happening? I would like to know how this process actually works; I have to assume it's mostly a computer, but maybe everyone walks into a big conference room and yells at each other about the prices of caths and brain surgeries. Pleasesend me an emailif you were involved in this process.
The fact that hospitals can charge different payers for the same procedure is well known and completely legal. That doesn't make you any less crazy. If the patient in question calls the hospital and asks why they charge $40 for the emotional assessment when Medicare only pays about $5, they may not have a good answer, but that doesn't matter anyway; she would still be contractually owed it. They could sue her ass for not paying for it. The same would happen if prices were higher if that was the difference between theman MRIthis costs $4000 at one hospital and $1000 at another.
This ridiculous situation explains a lot why the American health care system is so expensive. For some reason, health insurance companies are often very bad at dealing with hospitals. It's possible they don't care how much they pay for each procedure, as they can keep raising premiums. It might be too difficult to negotiate over 10,000 different prices. Either way, patients and employers who buy their plans have a hard time seeing what they're paying for and understanding whether it's fair. If your bill only says Medical Services, which is basically like saying Doctor's Stuff, how are you supposed to know if $200 is a steal or too expensive? Why does no one seem to care that all these prices are completely bogus?
All of this is confusing and angry enough to make the sanest person weep. If you're doing this in front of your doctor, just have your wallet ready.
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