Culinary Business Academy

Initial Business Response /* (1000, 10, 2015/10/13) */
Contact Name and Title: *** , Quality Ma
Contact Phone: XXX-XXX-XXXX
Contact Email: ***@mercy.net
Thank you for coming forward with the concerns regarding charges related to your colonoscopy procedureYour complaint was entered
into our Quality Management Review processYou are concerned:
You are being billed for a "diagnostic" rather than a "preventative" procedure
aYou stated your doctor wanted to perform a preventive procedure due to your age
You stated the doctor performed a biopsy and that biopsy was used to rule out cancer
You stated you spoke with a hospital representative and they said they would resubmit
You stated you received a follbill with the same charges
The investigation is complete and included interviews with staff, review of your medical record, review of coding, and a review of all charges related to the procedureFindings include:
Physician documentation of the reason for the procedure is "recent changes in bowel habits and stool character"
aIn fact, the preop diagnosis is Special Screening for Malignant Neoplasm, Colon
During the procedure the physician identified an abnormality and performed a biopsy
aA biopsy is a diagnostic procedure
There is record of the conversation you had with the representative
aThe resubmission was not for billing; it was for your procedure to be resubmitted for a second coding
The same results were found by the second coder
We are required by law to submit coding exactly as it found in the medical recordTo code your procedure as "preventative" would be fraudulentWe do not alter coding to change the charge of procedures
We have options to offer patients that are experiencing difficulty paying their hospital billIf you are having trouble please call XXX-XXX-XXXX to discuss optionsI want you to know the results of this investigation are being used to improve the quality of care we provide those that seek care from usDelivery of high quality, cost effective healthcare to the patients we serve is very important to usThank you once again for helping to improve healthcare quality and safety for all
Initial Consumer Rebuttal /* (3000, 12, 2015/10/20) */
(The consumer indicated he/she DID NOT accept the response from the business.)
THE COLONOSCOPY WAS A SCREENING PER MY DOCTORASK HIMI WAS NOT BILLED/CODED FOR A SCREENING PER MY INSURANCE COMPANYTHAT'S NOT RIGHT, AND I'M LEFT IN THE MIDDLE, RESPONSIBLE FOR PAYING FOR SOMEONE'S MISCOMMUNICATION OR ERROR
Coding or billing? Semantics to meThe phone number that was printed on the statement is what was used, as I have no idea what your departments are labeledAlso, calls were connected through my insurance provider, and I'm not sure which dept was contactedAgain, my insurance company stated that the procedure was not coded/billed as a preventative/screening, which is what is was supposed to be, and they told me to ask about getting the proper coding for thatI'm not asking anyone to commit fraud or any other crimeI just want to be billed/coded for the preventative colonoscopy that my doctor performed, and I agreed to
Final Business Response /* (4000, 14, 2015/10/27) */
Thank you for giving us the opportunity to investigate and respond to your complaintThe investigation is complete and included interviews with staff, review of your medical record, review of coding, and a review of all charges related to the procedure
Here are the definitions of a Preventative Colonoscopy and a Diagnostic Colonoscopy:
Preventive Colonoscopy with Screening Diagnosis:
Patient is asymptomatic (no gastrointestinal symptoms either past or present), over the age of 50, has no personal or family history of GI disease, colon polyps, and/or cancerThe patient has not undergone a colonoscopy within the last years
Diagnostic/Therapeutic Colonoscopy: Patient has past and/or present gastrointestinal symptoms, polyps, GI disease, iron deficiency anemia and/or any other abtests
Although your physician may have told you the colonoscopy was preventative, he documented in your medical record that you were experiencing symptoms of "recent changes in bowel habits and stool character" and your "father had a colectomy for rectal cancers"After the colonoscopy he also wrote: "awaiting pathology report for further recommendations in an attempt to explain change in bowel habits and stool character"As you can see, your situation fits the Diagnostic/Therapeutic Colonoscopy description
The charges related to your visit are for actual services provided to you; not for what the doctor said to you in the officeIn order to charge for services the coders read every entry in the medical record, they cannot code procedures based on conversations that are not documented in the medical recordWe submit coding exactly as it is found in the medical recordTo code your procedure as "preventative" would not be accurate as the doctor stated you were having symptoms, you have a family history of rectal cancer, an performed a biopsy during the colonoscopyThe coding and billing are appropriate
We have options to offer patients that are experiencing difficulty paying their hospital billIf you are having trouble please call XXX-XXX-XXXX to discuss optionsI want you to know the results of this investigation are being used to improve the quality of care we provideDelivery of high quality, cost effective healthcare to the patients we serve is very important to usThank you once again for helping to improve healthcare quality and safety for all
If you have any questions, please feel free to call me at (XXX)-XXX-XXXX
Final Consumer Response /* (4200, 16, 2015/11/03) */
(The consumer indicated he/she DID NOT accept the response from the business.)
Somewhere there are miscommunicationsIf I would have known all of this before the procedure was done, I would never have agreed to it, as I have no gastrointestinal diseases, and I am not taking any colon-related medication! Nothing has changed in my life as a result of this test, except I plan on never choosing your hospital again if I have any other options available, and I've made sure all of my acquaintances & co-workers are informed of your practices
I have recently been prescribed insulin & oral medication for diabetesThis medication gives me diarrhea, which is the "change in bowel habits." My father had a colostomy, because he was a POW, who was chronically starved almost to deathI'm sure none of this makes a difference to you, however
Again, I don't think it's right that I have to pay around $1,for a colonoscopy! It's disturbing that you have no problem billing an individual that much for a test($1,after my insurance has paid you, in addition to my monthly premiums, after my deductible has been met.) What's more disturbing is that whether or not the colonoscopy is preventative or diagnostic, the actual procedure is exactly the sameThe only difference is how you choose to bill/code itI don't even understand how that's legal!
One last thing, I don't have difficulty paying my billsI have a problem with the chargesIt's rude to keep implying otherwiseThe other hospital in my network usually discounts the remaining portion that I'm obligated to pay, and they offer a discount if paid with cash, so I don't receive enormous bills like this oneBut, hey, if $1,doesn't sound like a lot of money to you, that might be part of the problem