On the home page we covered Medical Billing. As you can see, it's not rocket science.

There are few true complexities with the act of medical billing. Anyone with a minor amount of education, as was provided on the home page, can do this.

• Paper billing was simple.
• Billing via software does in fact get quite complex. The way in which claims have to be created and queued for submission and tracked is complex. And if the software vendor wraps in outbound Invoicing and Accounts Receivable for outbound billing after the EOB comes back, the software becomes a train wreck, but let's go to juicier and grosser stuff first.

The problems with medical billing aren't with billing. They are with nefarious Billers and Accounts Receivable Agents and the very nefarious games they play (just as suggested at the bottom of the home page, but with the facts to back it up).

• The ability to manipulate the billing submissions for provider gain is really quite easy and quite large.
• The only person or person's capable of providing any feedback or cross-check are the uneducated patients.
• Unfortunately, uneducated patients won't try to study bills if their portion of it is small or negligible (<< thus the trick here).
• And even if they do most couldn't remotely figure them out...
• And for those that do figure then out and complain, the insurance companies will shoo you away like an insignificant nothing (yep. been there too. An $1800 bill for 45 minutes of silly breathe testing performed by a medical technician (not a doc, and not a nurse) that should have paid out about $200 per the vendor of the machines and software was complained about years ago. Blue Cross told me to buzz off... ).
• And then come the manipulation of the patients themselves by the billers. That's the second half of the fraud that is going to get a light so bright, few will forget it.

Emergency Room Visit Example

One of the biggest areas for billing malfeasance is Emergency Room visits. The hospitals rape and pillage and the insurance companies go along with it because they make more money if more money is paid out. Hospitals and insurance companies have avoided major upheaval in this area is by covering ER visits at 100% with low to no deductible. Thus, people aren't vested in the bill and the game rolls on.

The "average" cost for a visit to the ER for someone who falls off a horse with no discernible broken parts or internal bleeding seems to be about $35,000. The time with a doctor is typically in the 10 to 20 minute range. The total time in the ER waiting for tests and such is in the 2-4 hour range. The battery of X-rays, MRIs and CAT scans might total $1-2k in a country with realistic pricing.

Ah yes, the wonders of "modern medicine" and "medical billing scams" that have no equal.

The year 2019 for me is going to be marked by 3-5 surgical procedures, and it's going to marked by this website. A place in which I share with the world a level of nefarious billing that most have no clue exists. This is a world I've been familiar with for over 20 years. This is where people start to realize why our health care costs 4x as much as all other developed countries. Our healthcare is likely comparable or equal. It's the fraud that makes it 4x as much... Don't believe me? Wait til you see this...

This year will make for an exceptional case study. I was turned down for health insurance at age 22 in 1992. That is when I first saw under the hood of the Beast that is the US Corporate store. I saw the Corporate Store Beast's connection to Health Insurance for what it was then and have been on the run ever since.

I've been fully self employed since 2000, having to handle my own insurance for 19 years. I've had 16 surgeries since 1993 or so. I've had decades to look under the hood. I am prepared for every billing related shell game they have to offer this year, and they've not let me down so far.

Ultimately, my goal here is to expose the level of complexity, dysfunction and fraud inherent to our for-profit insurance system and to expose the reality that our for-profit insurance companies have ZERO INCENTIVE to stop it. They make a percent on all claims processed. They simple tell whoever manages increases there were more sick people and premiums go up. It's a fools game and the fools are all who are paying into the pot.

Few seem to be able to use common sense in this area for one reason or another. I'm hoping a case study for everyone to chew on may help out. Call me an idealist if you'd like. If you do, we'll toss every other first world country citizen with nationalized health care into my corner for a joust.

Medical Record Portals -- Each provider I'm going to this year is giving me an option to sign up for their portal to view my health insurance records. My GOD is this getting confusing and dysfunctional. In theory, if I want digital access to my records I have NINE different portals I'd need to log into. And get this... none of the portal names align with the providers. Also, one of the ones for the , and the one's I've tried to use are incomplete. All this 25 years into the digital age? This is abysmal stuff and it can only get worse if everyone is left to create their own for profit systems.

• SVMC Portal for Swann and Inlow > > http://www.healthportalsite.com/primecare (like I'd ever remember that, and Swann's stuff isn't in there b/c he and a few others are on separate management system not integrated to electronic access yet)
• SVMC Paper Records >> www.datafiletechnologies.com (like I'd ever remember that...)
• SVMH -- I can't even find the damn sign up email I was sent for that. I know I have it somewhere...
• Monterey Peninsula Surgery Center -- https://www.onemedicalpassport.com/ (like I'd ever remember that)

I'll post others when I can find references to them again. It's all so confusing I can't keep up with them...

Many of these items will get their own page once they flush out completely, but here's what I've seen so far..

1. 15 minute appointments have been billed as 45-60 minute appointments (E and M code abuse, very typical)
2. All MRI's and CT Scans are approved by code and facility, BUT the approval letters don't indicate that. The approval letters imply a code was approved and you can go anywhere you'd like.
   1. A 3 min CT scan that gets reimbursed at $75-150 by Medicare and Medicaid and one that gets reimbursed in the $200 range by insurance got reimbursed at $3500 with no flags from Blue Shield. The code used to bill was not the code approved for the service.
   2. Extremely complex adjustments made on MRIs resulted in credits for copays. It appears about $40 of my money was lost in the adjustment process (appears to be accidental loss).
3. Blue Shield started declining MRIs when I got to four or so with illogical and farcical excuses. The appeal process was lengthy and illogical. They said I needed to do PT before any MRIs could be authorized without a diagnosis on what was ailing me. When the MRI's were done they revealed a muscle tear and cyst in the elbow and a tear in the shoulder. PT could have done damage. Glad I didn't go.
4. Multiple seemingly unrelated facilities in the Salinas area all using Radiology Group from north of San Francisco. Extremely, extremely deceptive billing from the Radiologists (extremely deceptive). The group only works 9 days every two weeks. They only work until 3pm and there is no voicemail. The complaints on yelp validate my experiences regarding no voicemail and other "issues". You'll want to see this billing for sure. This deceptive billing doesn't appear accidental and this group is worth checking out for sure..
5. An imaging center in more affluent area seems to be getting reimbursed a premium for their services. Their billing also includes a misleading line item that they keep including for no reason that would lead some to overpay for services. Seemingly by design.
6. Just days before surgery #1, a surgery center indicated a $6-10k surgery was a $26k procedure. When questioned about it, no one would provide transparency related to three simple line items. All kinds of smoke screens were tossed out for diversions assuming I did not understand medical billing. After calling them on all of it, they tried to claim the mix up at the surgery center was due to an incorrect billing code that said I was getting a full ankle replacement. Problem with that is that the nurse from the surgical center called me 10 minutes after the lying billing manager got off the phone and the nurse knew I was just in for a bone spur procedure, contrary to what the billing person claimed the surgery had been setup for just 10 minutes prior. This is some really majorly corrupt sh-t by design and groups of folks in on it.

On Wednesday 8/7 I'll get two procedures in one! Right hip grinding and left elbow bone spur removal. Pre-op on Monday and I'll take up the other left elbow and shoulder issues then as the cortisone wore off and my left wing is generally hurting like h-ll. I wonder if the surgical center will shoot for a hip replacement code instead of the more appropriate hip grinding this time? That would be a much better number to bill. Pays about 20k more...

To be continued...