This outfit and what they are doing is simply mortifying from a transparency perspective and likely from a fraud perspective as well based on my initial interactions...

I first heard about "global billing" and "Global One Billing" in the surgery coordination letter related to a bone spur removal surgery on my right foot. That letter was dated May 29, 2019. That letter was written and sent by the surgery coordinator that works directly for the Podiatric Surgeon, Brian Inlow, who is part of a large group of orthopedic surgeons at the Salinas Valley Medical Clinic.

I have not seen much in the medical billing world that is healthy in the past few years. I remained hopeful about this consolidated billing idea until it was apparent the lack of transparency was off the charts...

On Monday, June 24, 2019, I got a call from Adam Carter with Global One Ventures. He indicated my upcoming surgery was $26,000, but the good news was that all I needed to pay to get on with the show (and reach my out of pocket max) was $1356.

Unfortunately, the problem with that is that a bone spur surgery should be in the $6,000 to 10,000 price range, not the $26,000 price range. Surely they'd give me a break down or a description of the surgery so we could cross check for any obvious errors right? Nope..

To quote Adam...“An itemized breakdown is not available per the contract with Blue Shield

Click here to read the full email string One with Adam at Global One and Nadia at Monterey Peninsula Surgery Center

This was a good one. it's not too long and exposes just what it needed to expose...

By 9am the day prior to surgery I had not heard from anyone at the Surgery Center.

I had a short email dialogue with Nadia. She confirmed a tentative time and she answered a few simple questions for me... one of that seemingly benign facts disclosed will come in very handy shortly!!

Click here to read the full email string with Nadia, this is a 1 minute read...

I had just gotten done with the email string from Nadia. I was pulling in the Costco parking lot and I got a call from xxx, the billing manager at Monterey Peninsula Surgery Center.

At 1150 am on Thursday, the day prior to surgery, just after I got the email from Nadia on a time to show up and just before I got a call from the nurse, Kenia Mangan called from Monterey Peninsula Surgery. She called me from 831-264-5561.

Kenia spent 5-7 minutes trying "explain" their bundled billing. She refused to give a break down of fees. She was informed I managed a wellness office and was familiar with CPT codes and billing protocols. Total call time was 11 minutes.

When she was unsuccessful with appeasing me with the bundled billing magic, she asked me what procedure I was getting. A terrifying question to be asked by anyone related to a surgical center. I asked her what procedure she had me down for and she said, "I have you scheduled for a full ankle replacement".

At that point, she started to get all excited saying things like, "this isn't correct, we need to get your surgeon involved, he's got you scheduled for a full ankle replacement and this all needs to be redone". All this happening less than 24 hours prior to surgery?

Calmly, I said "Kenia, please send me over the order my surgeon placed with you all showing this error". She was caught off guard. Needless to say, she said there was nothing to send me because my surgeon logs into their system and enters orders. I asked her to print of a screen shot of whatever she was looking at. She refused that too. I believe I also asked her when they ordered the replacement ankle as surely that had to be ordered days in advance. I believe I asked her for a copy of that order too, with no success.

About this time I blew a gasket. I told her that I was fully aware of what I was scheduled for, and it was an ankle replacement, and if she futzed up this scheduling in any way, I'd be a pretty mean person. Typically when I say things like that , it slows down or changes up the fraud. Not with Kenia. She didn't let it phase her a bit. I told her not to touch my scheduling and we got off the phone.

As Encylopedia Brown, new to this kind of thing, ask yourself this...

How long does a full ankle replacement surgery take?

Do we have any facts or statements about my scheduled surgery time that arrived just before my dialogue with Kenia? (yes, we actually do in that email with Nadia that came in just minutes before this conversation transpired... and I was only scheduled for 75 minutes in the OR...)

At 12:29pm a nurse from the surgery center called to go over timing from 831-753-5800.

• That call lasted 13 minutes.
• I was to arrive at 10:45, surgery start 11:45, 75 min allocation, 1pm - 2pm recovery and pickup.
• I asked her what I was scheduled for.
• She indicated a bone spur on tallis.
• I told her about the billing matter. I asked her how long a full ankle replacement would take and she did not know, but she said they were extremely rare.

It would seem Kenia made up a story to cover up for some type of error or planned billing manipulation, now the only question left is which was it...

Was this about an honest error or was this about a billing manipulation that could have been worth about $17,000 with almost no way to audit it...

The day of the surgery I saw/signed two docs for Global One. I asked for copies...

Sometimes, I wish I had pushed back less hard, and allowed them to "mis bill" this. But truth be told, they'd just do the same thing then as they are going to do now, and that is to state "it was a type in billing codes". The real question will be what they do when we go hunting for that typo...and how they are going to explain Kenia's behavior...

As you can see, with these custom codes, there would be no way to cross check this with anything.

And for what it's worth, the Monterey Peninsula Surgery Center website advertises bone spur surgeries for $6020.

At this point in time, I have no reason to believe this was simply a "typo on a cpt code from the surgeon". Everything about the scheduling aligned with a bone spur surgery including the time allotted for surgery, and that's what puts Kenia's statements about what they were prepared for in a darker light. The lack of transparency when both the surgery center folks and the global one folks were on the same email string was also very problematic.

So, how might this game be working and who might be involved?

Authorizations

• In order to schedule a surgery like this, I believe the Surgical Coordinator for the Surgeon would need to get Authorization from the insurance company. That authorization may or may not require any documentation.
• If the fraud starts with the doctor, he'd pass a bad code to his billing coordinator
• If the fraud starts with his billing coordinator, she could get an accurate code from the doctor but pass an inflated one on to insurance for authorization
• If the fraud starts with the surgical center, they might have a way to re-auth something after it arrives to them, based on a "typo" or something like that...

If the doctor is NOT involved, he or she bills Global One for procedure X for $1000. Global One bills for procedure Y for $3000 (along with a 20,000 facility fee vs a $6000 facility fee). Global One gets reimbursed for a far more complex surgery than what transpired, and the doctor is only paid out his $1000 having no clue the intermediate biller may have just made out like a bandit.

Also, there is some question as to whether Blue Shield cross references authorizations with bills. B/S authorized a CT scan for my hip. It was done at a hospital, under a different code. The hospital billed $3500 instead of $150 and was reimbursed for it. Yeah... we've got some serious issues going on...

While I would initially agree this all sounds a little far fetched, being denied all information to validate an illogical bill was unsettling. Then being talked to like a 10 year old with no billing experience from two Monterey Peninsula Surgery Center folks who do nothing but bill in a way that was not transparent was discomforting. Finally, being told less than 24 hours prior to surgery that they might replacement my ankle instead of knock off a big one spur was simple terrifying...

9/16/2019 -- I'm starting to draft some letters now. I may not send them out for a few weeks, as I have some other irons in the fire now that are getting quite hot (have ya seen the latest update to the Salinas Valley Radiology page!? YIKES. That's getting hot.. I'll let you know when this starts to pickup more... Stay tuned...