Sutter Alhambra Surgery Center

Review: Sutter Alhambra Surgery Center (“the Center”) has engaged in an unsubstantiated billing increase that constitutes fraud on its patients and the insurance network to which it bills. As indicated in Attachment 1, the information ledger, the Center called me prior to my surgery and asked that I pay $932.00 based on their cost estimate of the CPT codes for my procedure. Following the procedure, I received an additional bill from the Center for $716.58.

Of that $716.58, I concede that $350 was a deductible that my insurance mistakenly applied in another billing but subsequently removed and therefore it is appropriately applied as an additional billing. (See Attachment 2, EOB.) That leaves $366.00 in unaccounted billing. When I called the Center, a representative explained to me that the change in the amount estimated and the amount charged is the result of two things: 1. A change in the equipment required during the surgery; and 2. A change in the CPT code. The CPT codes from the estimate, as reflected in Attachment 2, the EOB, were 28045 and 28296, respectively. Attachment 2, the information ledger, indicates that I was ultimately charged under 28045, 28296, C1717, and A4649.

With respect to the first issue, two additional codes were added. C1713 indicates a cost for an anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable). Although the Center could not explain what screw was used or what it cost, the charge was $982.00. A4649 indicates costs for miscellaneous surgical supplies, which were also not explained by the Center, yet warranted a cost of $1,081.00, over 15% of the total cost of the procedure as estimated.

With respect to the second issue, there are two major problems with the Center’s billings that indicate fraud. First, there was absolutely no change in the CPT Procedure codes between the estimate and the billing. Yet, somehow, the Center first estimate of $6,213.00 for both CPT procedures became $8,040.00 for both procedures in subsequent billing. No reason could be articulated to me why there was a 33% increase between the first and second billing. In fact, the representative I spoke to at the Center indicated that, if the CPT code remained the same, the cost should remain the same. Second, the charges for these CPT codes, for both the estimate and the final billing, far exceed the national average of this procedure, which indicates an average cost of $2,395.59 for 28296 and an average cost of $1,414.28 for 28045. This means that the Center is charging double the national average for this procedure.Desired Settlement: Ultimately, I am willing to pay the $350 for the error related to my deductible. I refuse to pay all other costs above the estimate I already paid until the change in costs is explained to me in detail. Without such explanation, I believe that the Center has committed insurance fraud.

Business

Response:

Please see attached. The patient was informed by our verifications department prior to the surgery that her payment amount was an estimate, that there may be additional costs due to the number of additional supplies or implants (plates, screws, drill bits for example), that can not be fully determined until during the time of the surgical procedure. After the procedure, phone calls to the patient have been attempted by the regional business office prior to submitting the bill to collections, per policy. The patient's insurance coverage is 85%, where the patient is responsible for the remaining 15% of the allowed amount, hence the added charges to the patient that her insurance did not cover. Sutter Alhambra Surgery Center is strictly regimented in ensuring proper billing protocols per policy. We billed the patient accordingly to the insurance plan she signed up for, ensuring that the Surgery Center is following the policy and protocols of both the hospital group and her insurance company. The estimates provided during verification (prior to services rendered) are only an estimate based on how the procedure(s) is scheduled by the surgeon. We provide this information as a courtesy to our patients to assist with understanding their benefits and being prepared. On the attached Pre-Payment Agreement it clearly states the following: "Additional procedures, implants, and or supplies will be billed after you insurance processes your claim." "This is only an estimate." "The amounts provided prior to surgery are estimates only. Actual benefits, to include patient responsibility, cannot be finalized until your insurance company completes processing your claim. You will be responsible for any difference." This form was signed by the patient and a facility witness on 06/04/15. A large part of the difference in this case is due to implants and supplies being billed. We cannot know all implants and supplies that will be used during a procedure before the services are rendered. This is why we state clearly on the Patient Pre-Payment Agreement explained to and signed by the patient that, "Additional procedures, implants, and or supplies will be billed after your insurance processes your claim." Ultimately this is a decision made by the surgeon based on patient needs during the procedure(s). If you have any further questions please feel free to contact the [redacted]

Consumer

Response:

I am rejecting this response because: