When I tell people that I found evidence of double-billing on my doctor’s bill, they imagine the effort must have been a deliberate attempt to defraud the insurance company. Honestly, I don’t believe that. I trust my surgeon. When I look at the transcript from my back surgery, I see a clear, precise statement of what was done. Nothing in those notes says, “bill twice for this operation.” How, then, can anyone explain a bill that lists both

22630    Arthrodesis, posterior interbody $4,600.00

and a few lines later,

22612    Arthrodesis, posterior or posterol $4,600.00

for a single fusion? Arthrodesis (and, yes, I had to look up that ) is the permanent immobilization of a joint—a removal of the soft tissue and a fusing of the bones to either side. For a spine, arthrodesis requires that a disc be removed and the two vertebrae then be bound together. I had only one disc removed. How can a surgeon perform this procedure twice for just one disc? I’ve read through the surgeon’s notes for the operation, and nothing in them suggests any duplication of the procedure. Is this bill just a simple misreading or a quirk of the coding system?

Unlike the confusion over my back brace (see Hidden in Plain Sight, Part 1), reading the full translation of the two reported codes (22630 and 22612) doesn’t provide much help in making sense of the bill.

22630—Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar—looks like a perfect description of my surgery.

22612—Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)—looks out of place, an unnecessary repetition of a piece of 22630.

Did the fact that the insurance company contractually denies $3,794.20 (allowing only $805.80) for procedure 22630 but denies only $2,923.25 (allowing $1,676.75) of code 22612, explain the doubling in the bill? Also, the doctor’s office billed for an additional $1,600 for each procedure for the doctor’s assistant. Does the fact that the double billing was duplicated for the assistant prove wrong-doing? Possible… but I really believe this is unlikely.

What? Am I the same guy who, in Part 1 of this series, said, “I wuz robbed”?

Sure, but isn’t that everyone’s gut reaction? We see a wrong and it should be righted—preferably by someone armored and riding a white charger. Some of us even grew up wanting to be that white knight.

Well, fantasies can be fun for daydreaming, but they don’t buy the groceries.  A little bit of calm reasoning tells me that I really have just two choices in reading these errors:

  1. My surgeon’s office—in addition to performing diagnostic services and doing surgeries—is a front for a conspiracy to bilk consumers (the kind of ingenious scheme that could only be countered by some sort of Special Forces unit armed with…sorry, getting back into the fantasies).
  2. Something far simpler and far less sinister is at work, probably an accumulation of the kind of flaws that bureaucracies naturally spawn.

Choice one is ridiculous. I vetted this surgeon through my orthopedist and pain specialist. I also spoke with him extensively prior to the surgery. He’s a great surgeon with an excellent record and a detailed understanding of my problems. I respect the man’s skills and trust in his integrity. Why would I suspect him of wrongdoing?

Besides, looking at the way doctors bill, suggests that choice 2 really is the more likely case. Most medical offices have separate coders and billing agents. The billing agents usually don’t even need to know what the codes mean in medical terms. This surgeon’s billing agents need only know that they are supposed to bill $4,600 (plus $1,600 for the assistant) any time the code said either 22612 or 22630.

Doctor to transcriptionist to coder to billing agent: through such a line of communication, errors creep in. It would be more comforting if they had one more layer of checking—someone who could look at the bill and say, hmm, why are we billing for the same procedure twice? Of course, an extra level of QA would increase the overall bill.

So, now I’ve gone through my doctor’s bill,  translated his coding, and I know where the charges from his office don’t make much sense. I’m just about ready to contact his office and begin negotiations.

First, though, I really should check the surgical records and notes against my bill from the hospital. Part of the money that I paid directly to the hospital went into this doctor’s bill. Before I start negotiating, I need to be sure where all the money went and where it was supposed to go.