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By Shirley Eileen Fitzgerald, RN
Consider the case of Mr. Myers, a 45-year-old, white, male executive, hospitalized following an important business lunch with complaints of chest pain. He is greeted in the Emergency Room with the usual treatments, including cardiac monitor, EKG, oxygen, nitroglycerine, and so forth. An hour later, he finds himself under observation in the Cardiac Care Unit with the diagnosis of “rule-out MI,” already the recipient of an exorbitantly expensive medication known as a “clotbuster.” Noting that his chest pain seems to come in waves and is unrelieved by increasing doses of intravenous nitroglycerine, an astute RN acting under standing orders gives a dose of the pain-relieving medication: morphine sulfate. The pain increases and the RN notifies the physician of her observations. (Years ago in nursing school she had learned how morphine increases pain through action on the sphincter of Odi allowing differentiation between gallbladder attacks and myocardial infarctions.)
At this point, it would be expected that if the patient’s vital signs are stable, he could be transferred to less expensive care on the medical floor while the work-up for gallbladder problems was completed. But cardiac orders remain on the chart … blood specimens for cardiac enzymes every eight hours, additional EKG’s to be done and intravenous anti-coagulant therapy to follow the “clotbuster.”
Eventually, Mr. Myers leaves the hospital on a reduced fat diet and minus his gallbladder. But then there’s the bill. A bill Mr. Myers will probably never look at and would have difficulty deciphering if he did. He was just happy to be out of the hospital and his insurance would be left to deal with the bill.
Let’s take a critical look at this hospital bill:
1. Emergency Room: billed for services by the hour; all services were ordered by an MD and reasonably necessary,
2. Critical Care:
a) Why is there a charge for oxygen tubing? Can he use the same one he got in the ER?
b) Why wasn’t he transferred out of Critical Care within two hours of the differential diagnosis?
c) On the day of transfer, is Mr Myers charged for both a day in Critical Care and that same day on the medical floor?
d) Cardiac monitor electrodes are transferred with the patient from the ER, but he was charged for more when he got to Critical Care.
e) Once the second blood specimen for cardiac enzymes showed no abnormal elevation, why did they continue to be drawn every eight hours?
f) Why was the intravenous anti-coagulant continued after it was determined to be a gallbladder problem? (It delayed the gallbladder surgery by more than 24 hours.)
g) Why were additional EKG’s done after the gallbladder diagnosis? Couldn’t the orders be canceled with MD approval?
h) Now let’s count the intravenous solutions given … every time the solution is changed, there is a possibility of being charged for solutions dispensed by pharmacy, not given to the patient, returned to the pharmacy for use with another patient, yet not credited to the first patient’s account.
Check the oral and injectable medications as well. When you’re being charged upwards of $5.00 for each aspirin, this can really add up. If in doubt, compare the medication administration record with the pharmacy charge portion of the bill.
For patients with private insurance where itemized billing is still provided, my experience has shown an average of 20 to 35 percent in overcharges to be common. HMOs avoid some of this scrutiny by itemizing only the charges known as “co-payments” for certain procedures, and many hospitals have gone to the system of charging an all inclusive blanket fee for a particular type of care per day in critical care to avoid billing challenges. Perhaps the best solution I have seen encouraged patients to scrutinize their own bills and rewarded them with a 50 percent refund of the amount of any overcharges they were able to get refunded by the hospital.
Shirley Fitzgerald is president of Med-Legal Consulting, Inc., and is affiliated with American Association of Legal Nurse Consultants, Oregon Women Lawyers. She can be reached at (503) 629-5109.
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