Patients keep getting charged for crying
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People hate Twitter for a lot of good reasons, but it undeniably rules when people post their insane medical bills and it goes viral. This week, a woman in New York tweeted about her sister’s bill, which ostensibly included “$40 for crying.”
The tweet was similar to another post that went viral last year: A person whose bill for a mole removal included $11 for “Brief emotion,” which the poster assumed was because she cried. She got $2.20 off, though.
The “Brief emotion” line in the second tweet is short for “brief emotional/behavioral assessment,” the same charge as in the first tweet, which falls under CPT code 96127. (You can just see the end of the code on the left column there.) 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.” So neither patient was charged for crying, per se; they were charged for being screened for depression or other mental health problems. The American Academy of Family Physicians says that this code should only be used for “purely preventive” screening, not based on signs or symptoms—like crying in the doctor’s office, for example. Hmm!
Let’s back up—what the heck are CPT codes? Current Procedural Terminology (CPT) codes are an insane language of medical billing. They exist to assign value to every imaginable medical procedure and activity, from a physical exam to a circumcision. Providers use these codes to bill payers, like insurance companies or Medicare, or you, if you’re uninsured. Almost all medical care in the US is paid for with a fee-for-service model, which reimburses medical providers for care provided based on their activities, explaining why you get these bizarrely specific line items and inscrutable codes on your bill. These codes are extremely useful to know about if you ever want to challenge a medical bill, because you can easily find out how much Medicare reimburses providers for these billing codes using their Physician Fee Schedule search.
Using this tool, we can discover that Medicare pays between $4-6 for 96127, depending on location—ten times less than what the patient in the tweet was billed.
The fee-for-service model encourages providers to find more and more expensive codes to assign to their activities, spawning a whole industry of advice and expertise on how to “maximize revenue” through medical coding. I found a blog post on the site Therapy Notes specifically about using code 96127 to juice revenue:
96127 can be billed up to four times per client, per session. This means that you could administer, score, and bill for up to four separate instruments to each client every time they come in for a session. A brief survey of reimbursement rates across major insurance companies shows that you can earn an additional $4-$8 per instance of the code. Combining the 96127 code and MIPS payment adjustments, if a Medicare beneficiary comes in for 15 total sessions plus an intake, administering four instruments per visit and successfully reporting MIPS data could potentially increase your revenue for this client by nearly $400! Check with your payers to see how this code is reimbursed.
This post seems to be encouraging therapists to administer four separate screening tools for different mental health diagnoses, every single session. I am no therapist, but I am depressed, and with each new provider I greet the 9-question depression screen like an old friend. I cannot see how filling it out every single session could possibly be a good use of the limited time you get with a therapist—let alone filling out three others too. If I didn’t have ADHD last week, I probably don’t have it this week. This sort of thing is a dark art for medical providers: When they do it wrong, that’s called upcoding, and it’s illegal. When they do it right, it’s just ‘maximizing revenue.’
There’s a lot of lessons for patients to be drawn from these two examples of billing madness, and this one little CPT code.
First: When it comes to medical bills, it’s difficult-to-impossible to know what you’re being charged for. In the case of the 2021 tweet, the patient reasonably assumed that “Brief Emotion” meant that they were charged for crying. (It’s not a particularly absurd assumption, given that new parents get charged for holding their newborn babies.) The purpose of the itemized bill is ostensibly to lay out what the patient or their insurance is paying for. How are you supposed to know how reasonable the charge is if it just says something like “Brief emotion” or, for that matter, “Physician Ser?” We have this very comprehensive (if bizarre) system of CPT codes, which provides a standardized language for communicating medical information, but bills don’t have to include those codes. There’s no standardization of medical bills at all. I have a bill for a few months of therapy sessions on my desk right now, and there’s no CPT codes on there. This sort of inconsistency and vagueness makes it hard for patients to know what they, or their insurance, is paying for.
This leads me to the second lesson: Hospital price transparency rules are useless. You could imagine this anyway from thinking for more than six seconds about how sick patients pick where to get treatment, even if it’s not an emergency, but the way the rules have been implemented makes it even more impractical to actually use this data. Hospitals don’t have to post these files in a format that patients can easily read, or in any kind of standardized format. I looked at a couple hospitals in New York City, since that’s where this week’s tweeter is located, and it’s a nightmare.
New York Presbyterian, one of the biggest hospital systems in the city, only provides a .JSON file that opened as an unreadable wall of text for me. (There are ways to make these readable, but I frankly don’t know how, and no one should have to know this to read their price list.) Northwell Health, meanwhile, has a comparatively usable chargemaster, though it has no CPT codes; just mostly incomprehensible descriptors, like “BRACHY PLAN C” and “SP BX LUNG MEDIASTINUM SISC.” Their list price for the brief emotional/behavioral assessment is $75, but it tells us nothing about what they charge different insurance plans, unlike competitor hospital NYU Langone.
NYU has a ‘chargemaster’ that is simply enormous, with over 48,000 rows. My 18-month-old MacBook Pro could hardly handle opening it, but I was finally able to find out NYU’s ‘list price’ for CPT code 96127: An astounding $118, about three times what the tweeter’s sister was charged and 23 times what Medicare pays. (The list price is made up. Doesn’t mean anything.) The NYU chargemaster also shows its prices for various insurance companies are all over the place. Some pay $6. Others pay $45, or $75. Emblem Essential Plan will pay $116, just two dollars off the list price. The ‘discounted’ cash price is $29. Even if you knew how to find this price list, owned a computer, and were able to open and navigate the massive spreadsheet, there’s almost no way you would know you were going to be charged for this assessment before you arrived, or what it would be called, or what its CPT code was. The price list is useless.
This brings me to the third lesson: Prices in healthcare are wildly inconsistent. They generally lead to more questions than answers. Why was the mole removal patient charged $11, but the patient in this week’s viral tweet charged $40? Why does NYU Langone charge some insurance companies $6 and others $116 for the exact same thing? CVS Group, which owns Aetna, is the biggest insurer in the state of New York, and Aetna pays $71 for code 96127 at NYU Langone. Shouldn’t their market position have allowed them to negotiate a price better than 10 times the top Medicare charge? There are more than 10,000 CPT codes; how do hospitals negotiate such wildly varying prices for every one with so many different insurance plans? Like, literally, what happens? I would love to know how this process actually goes down; I have to assume it mostly involves a computer, but maybe they all get in a big conference room and yell at each other about the prices of catheter insertion and brain surgery. Please email me if you have been involved in this process.
That hospitals can charge different payers differing amounts for the same procedure is well-known, and also completely legal. That doesn’t make it any less insane. If the patient in question called up her hospital and asked why they charged $40 for the emotional assessment when Medicare only pays around $5, they could not possibly have a good answer, but it wouldn’t matter anyway; she would still owe it, contractually. They could haul her ass to court for not paying it. The same would go if the prices were higher, if this was the difference between an MRI that costs $4000 at one hospital and $1000 at another.
This ridiculous situation explains a lot of why American healthcare is so expensive. For whatever reason, health insurance plans are often really bad at negotiating with hospitals. It’s possible that they don’t really care how much they’re paying for each procedure, given that they can just keep raising premiums. Maybe it’s simply too difficult to negotiate over 10,000 different prices. Either way, patients and the employers who buy their plans find it difficult to look at what they’re paying and understand whether it’s fair. If your bill just says Physician Services, which is basically like saying Doctor Stuff, how are you supposed to know if $200 is a bargain or criminally overpriced? Why doesn’t anyone in charge seem to care that all these prices are just completely fake?
All of this is baffling and enraging enough to make the most sensible person cry. If you do it in front of your doctor, just have your wallet ready.
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