State:: Arkansas

Occupation:: Retired

Male, age 73, 5’-6”, 160 pounds, no personal physician, no drugs beyond occasional aspirin, no health issues besides mild Psoriasis.

Brief Summary of inpatient Medicare A coverage Denial by XXXXX Hospital:

I had a brief fainting episode at a late afternoon club gathering and was persuaded to let an Emergency service called by friends take me to a hospital emergency room where a doctor said he needed to keep me overnight. I asked if he was admitting me to the hospital, if I would be covered by Medicare A, and said I would not stay if not admitted. The doctor said the records department would take care of that in the morning. When taken to a room I asked again if I was admitted and covered by Med A and the young man said the paperwork said observation and that Med A would cover all expenses except medicine for 24 to 48 hours. The next day I continued to ask if I was admitted and covered and a lady from case management was called and said she would check, but did not verify yes or no and said to ask the case doctor. Late in the afternoon a lady doctor came and said they had found nothing wrong with me and there were more tests she wanted run before I was discharged and she repeated that Med A would cover all expenses except medicine. I was eventually discharged around 4:30 that afternoon. No one, at any time, said that I was not admitted to the hospital and the term outpatient was never mentioned. I later received a $450 bill for “ALS 1 Emergency, a $558 bill from the hospital doctor(s) on which I was listed as “PR OBSERVATION/INPATIENT HOSPITAL. CARE, LEVL5”, a $10,416 bill from the hospital for “Outpatient Services” with insurance listed as “None”, and a $237 bill from a radiology company; that’s $11,661 for one overnight stay, four potassium pills, and a suggestion to take over-the counter Prilosec for indigestion.

DETAILS:

9/25/2015
I had been working outside all day climbing up and down a ladder, and while I had not eaten since breakfast, I had been drinking water – three 18 to 20 Oz glasses during the day. I drove to our xxxxxxx xxx car club’s garage clubhouse for a cook out at 6:00 and arriving early I had one beer and then another while standing and talking/listening to a member for about 30 minutes. We started to move back from the garage doorway because smoke from the grills was blowing in when I suddenly felt very hot, began perspiring heavily, felt dizzy, and apparently started to or did faint. Next thing I was aware of I was sitting in a chair telling folks I was all right when they later said my eyes glazed over and I appeared to faint again. Someone called 911 and the xxxxxx EMS came and checked my blood pressure which they said was low (80 over 65?) and did some sort of electrocardiogram and said my hart beat was irregular and recommended they take me to the emergency room at xxxxx Hospital. The club president advised me to go, and I allowed them to load me up in an ambulance on a gurney. In the ambulance they kept asking me if I had trouble breathing or had any chest pain and I said no (I think they asked me that at the club shop too, to which I said no also) but in the ambulance they started an IV and oxygen to my nose anyhow. I was told I might be dehydrated and the IV was saline solution to hydrate me. At the xxxxx Hospital emergency room I was feeling OK and pretty much recovered and was seen by Dr. xxxxxx (He did not give us his name at the time but I was later told by the billing department that he was one of two attending physicians) who said he needed to keep me overnight since I had fainted. I asked him if that meant he was admitting me to the hospital because I had read the horror stories of folks who thought they were admitted but were not and their Medicare A would not cover them unless they were admitted. I told him I was OK and would not stay unless I was admitted and covered by Medicare A, and he said that would be taken care of by the records department (?) in the morning and he needed to keep me overnight because of the fainting and they were waiting to get me a bed. They wheeled me to another area where I was asked to sign a form which I could not read because my glasses had been lost. The girl said it was just a form that said my wife wanted them to check me out. I was later taken to a room on the 7th floor and I asked the young man who situated me in the hospital room if I was admitted to the hospital and he said the paperwork said observation. I asked if that meant I was admitted because (again) I had read stories of folks who thought they were admitted but were not and that Medicare A would not cover their expenses without hospital admission. He said he would ask someone and came back a little while later and said he was told that Medicare A would cover the hospital expenses up to 24 or 48 hours and I would only have to pay for any medications I received. I believe it was during the night that they came and took me for an MRI or some procedure in a machine, and the whole time I was on an IV that I was told was saline solution for hydration and I was attached to a portable heart monitor with a dozen or so electrodes attached to a device placed in the pocket of the hospital gown. The attendant asked me to promise not to try to get out of bed by myself and to call him if I needed go to the bathroom; there was a sign posted on the door that said “fall risk”.

9/26/2015
I continued to ask the same questions the next day of all the attendants who came into the room – was I admitted to the hospital and did Medicare A cover the hospital expenses – and each time was told the person would check, that I should ask someone in case management or other (accounting?), or to ask the doctor over my case, Dr. xxxxxx, who I had not yet seen. I almost left that morning when no one could confirm that I was admitted, but they kept saying that the doctor or the case management worker (?) would be there soon to answer my questions. They said the Dr. started rounds on the ground floor and would work (his or her) way to the top floor and asked if I needed to see a Case Management person – I said yes. Sometime that morning or afternoon a lady from the Case Management dept. (?) came to the room and I asked her the same two questions – was I admitted and were the hospital expenses covered by Medicare A – and she said she would have to check with someone. Also during the day an attendant brought four pills that she said were potassium pills that they needed me to take. During the day they took blood samples periodically and measured urine output, and I was allowed to take a shower which left me in a hospital gown only after having slept in the shorts and T shirt I had been wearing at the club shop. My wife came back around 11:00 with fresh clothes. They also did an ultrasound of my heart that day while she was there. When Dr. xxxxxxx finally came to the room late in the day, she said the same thing the night attendant had said – that the hospital expenses and tests would be covered by Medicare A and my expenses would be just for medicine administered (which at that point was four potassium tablets that were brought during the day). She said she wanted one more test done and that after that I would be “discharged” and that they had found nothing wrong with my heart, and that an extra beat now and then that they observed (It was monitored the whole time) was nothing unusual. She suggested that I start taking over-the-counter Prilosec for indigestion. (My wife remembered that she said she would send the case management lady back to confirm coverage, and that a lady did come to the room, but she did not give us any real information.) After the final test (I believe it was an ultrasound of my carotid arteries) I was fed lunch and then (I believe) given a discharge form to sign that the girl said was just routine and was finally rolled out the door about 4:30 (?).  At no time did anyone say that I was NOT admitted and the phrase “outpatient” was never uttered.

10/2(?)/2015
The next week I received a call from the xxxxx saying I owed $450, which the girl said she could reduce to $250 and I could make payments, and later I received an undated invoice from xxxxxx as a “Statement of Physicians Services” for $508 ($323 for Dr. xxxxxxx and $185 for a xxxxxxx of xxxx Cardiology Physician Plaza). Dr. xxxxx’s charge was listed as “PR OBSERVATION/INPATIENT H” with a due date of 10/26/15. I called xxxxx 10/21/15 and asked for an itemized invoice since I had been told I would be responsible only for medication, and the lady, xxxxx, said she would send one and that there was another invoice for $6,000 plus.

10/24/2015
I received another invoice from xxxxx for $6,770.41 for “Outpatient Services” that said it is due 11/3/15, the exact thing I had been concerned about and asked about from the first encounter at xxxxx and had been assured that my stay was covered by Medicare A. This is apparently the scam I had read about and been warned about that I wanted to avoid. I tried to call xxxxx 10/24/2015 to ask for an itemized invoice, the name of the doctor who said he needed to keep me overnight, a list of medicine they provided, and copies of any forms I had been asked to sign without reading, but a message says the offices are only open on week days.

10/26/2015
I called xxxxx at 1-855-xxx-xxxx and after a 5 minute wait I spoke with account specialist xxxxx and told him I had a bill for nearly $7000 after I had been told that the hospital costs would be covered by Medicare A and I would have to pay only for medication and I needed additional information and I asked for:
The name of the doctor who admitted me
An itemized invoice
A list of medications given
Copies of all forms I had been required to sign without reading
A list of charges submitted to Medicare, charges refused, and reasons given.

xxxxx said that I probably should not have been sent that bill because there is an adjustment pending of $8,402.XX on the $10,XXX bill that would leave a balance of $1023.98. (the math is still off by $1000 if I heard the numbers right , 10xxx – 8420 = 2024) I asked xxxx if I should just wait for further information, and he said yes. I asked again for the admitting Doctor’s name and he said the doctors were Dr. xxxxx and Dr. xxxxxx attending.

I still feel I was deliberately lied to by the staff at xxxxx to keep me there. They were all very nice, but also deceitful. I still feel I may need the help of someone familiar with this practice of semantic sidestepping and deceptive billing, but need to see what the final invoice is.

11/3/2015
I registered on the xxxxx web site to look at the billing information and it showed $10,416.02 for “Hospital Services”, -$7.50 for “Payments/Adjustments”, $10,408.52 for “Insurance Balance”, and $0 for “Patient Balance”.

11/4/2015
Had a message left by xxxxxx with xxxxx customer service while we were gone asking me to call xxx-xxx-xxxx

11/6/2015
Checking the xxxxx hospital site for current billing information:
Visit on 09/25/2015 to 09/26/2015 with xxxxxx at xxxxx Hospital Northwest Arkansas
I got this detail below for “Hospital Billing”. It now shows $10,416.02 for “Hospital Services”, -$7.50 for “Payments/Adjustments”, $0 for “Insurance Balance”, and $10,480.52 for “Patient Balance”. When I had looked at the site on 11/3/15 it had shown $10,480.52 for Insurance Balance and $0 for Patient Balance.

11/10/15
I called for xxxxxx with xxxx customer service (had left message 11/6/15 asking me to call 855-420-7900) and got xxx. He said xxxxx had called to ask if I had any insurance besides Medicare and to tell me it did not cover physicians’ charges. I told him I had just Medicare A. I told him the staff and the doctor said all the hospital costs would be covered by Medicare A and that my only expense would be medication given. I asked him for the following:
A detailed itemized invoice for Hospital and doctors
A list of medications given
Copies of all forms I had been required to sign without reading
A list of charges submitted to Medicare, charges refused, and reasons given.

xxx said he would send the account back for review (insurance review?). He said the records showed potassium chloride as the only medication given. He asked if I wanted a call back after the review and I said yes a call or email. He asked when my Medicare A took effect and I said I’d been paying for it for 45 years. After the call I looked up my Medicare card and it showed 09/01/2007 so I called back and this time got xxxxxx and gave her the Medicare effective date. She looked up the account too and saw that it was to be reviewed and said it looked like Medicare A should cover it. She added the Medicare date and said as long as it was in effect the review would show it. She did say also that Medicare A does not cover the physician’s charges.

11/11/15
I received another bill from xxxxx for Drs xxxxxxx, xxxxx), xxxxx, and xxxxx for $558 due 11/26/15 . The last two are both $25 each for an electrocardiogram report.

11/20/15
I received a two page itemization of hospital services that includes “4 0250 potassium chloride 10 MEQ tablet sustained rele” for $7.50 which must be what the $7.50 Medicare payment was for. Financial Class is “SELF”, Primary Payer is “None”, Patient type is “Observation”, the total is $10,416.02, and there is an “UNINSURED DISCOUNT (ACCT) listed 11/06/2015 as -3,645.61. None of the other things I asked for were included.

11/22/15
I went to the www.xxxxxxx.net web site. Under health summary it says “fainting” 9/25/15. Under billing it shows physician billing $558 and hospital billing $6770.41. Under details for hospital billing it shows $10,416.02 – $3645.61, Total Balance $6,770.41.

Also under appointments/past admissions it says ”You have no hospital admissions on file.”

11/27/15
Received another invoice from xxxxx for $558 for services from four doctors. There has been no reply or information about resolution of a review of the case that xxx said he would submit on 11/10/15.

12/12/15
Received yet another invoice from xxxxx for $558 for services from four doctors with xxxxxxx, xxxxxxx, MD services listed as “PR OBSERVATION/INPATIENT HOSPITAL. CARE, LEVL5”. There has been no reply or information about resolution of the review of the case that xxx said he would submit on 11/10/15 and the xxxxx web site still shows Hospital Billing as $10,416.02 – $3645.61 (Uninsured Discount), Total Balance $6,770.41.