And the band plays on…



For those of you that haven’t followed the harrowing tales of my admission to Bayfront Medical’s Emergency Room on June 3, 2014 you can catch up starting with Chapter 1 of the saga.  Today we’ve reached a milestone with my claim. I like to call him Bob because just calling him by his impersonal name ‘my claim’ is starting to make him feel unwanted.

Today I received the twelfth bill for $10,764.14 from Bayfront Medical.  I recently called them to find out how the processing of the claim with my insurance provider (Blue Cross Blue Shield MA) is going and they told me that they’re “…still working on it…”  So this week Bob is 1 year old and in case you weren’t aware, claims age differently than people.  Every year in claim years is like 20 years in people years.  As such, I’m happy to announce another wonderful event – Bob met someone.  Another claim came into our lives in January of this year.  To protect the innocent I won’t share who this claim is associated with but for those of you that are in the biz – it is a person who has added me to their HIPAA consent list for their account so that I may advocate on their behalf.  The new claims name is Edith.  Now Edith is a CPT code 72148 which for those that don’t speak medical billing short-hand is a MRI Lumbar Spine w/o Dye.


Edith resulted from a diagnostic exam ordered by a physician in response to the patients injuring their back while on business travel.  The diagnostic imaging center presented the patient with a waiver that stated that in the event the insurance provider fails to reimburse for the procedure they would be financially accountable.  When you’re in pain and want it to stop you’ll sign just about anything – right?

So fast forward, it’s now 5 months later, Edith is almost 10 people years old and the insurance carrier in question (Aetna) has denied the claim citing improper pre-authorization.  The imaging center wants payment for $1,126.00.  Hmmmm – that seems excessive – doesn’t it?

So I called and spoke to helpful billing person A.  This young lady explained to me that it’s the patient’s responsibility – blah blah blah.  I told her that I understand all that but that the patient is looking for a discount from full retail as that is not an appropriate amount.  I was told by billing person A (on a recorded line) that their policy is to cite Medicare Global Self Care Rates.  This is good for me as I can look up medicare reimbursements rates and so she came back with a discount to $675.60.  I thanked her and hung up and then went to look it up myself.  According to CMS, this procedure is reimbursed at the rate of $222.04.  Back on the phone I go and I get helpful billing person B.  This new young lady tells me that she has no idea why billing person A would say they use Medicare as they do not and moreover that the discount is only 20% off of $1,126.00 or $900.80.  I told her that that isn’t going to work as $675.60 is already on the table and the real reason I’m calling is that medicare will pay $222.04 and you’re asking for 3 times that and I would like and explanation as to why.  She couldn’t explain anything and punted to her supervisor who of course is in a meeting and will need to call me back.

I post this today as a cautionary tale – many of you are aware that most providers have agreements with insurance carriers to accept their payment and not try to balance bill you as the patient for any additional fees.  This of course all goes out the window if you sign a waiver.  Now I’m not saying that the patient in this instance was wrong for signing the waiver nor am I saying that the provider is predatory for having such a waiver.  I am however highlighting once again the wild disparity between what a provider will accept for a 67 year old versus what the extort from younger patients.