CAMC surgical nurse Cathy Cunningham — who speaks without jargon — is there when surgery bills begin. During an operation, she said, one nurse often takes notes while another helps the surgeon. "All procedures have a code, and you have a case cart with all the supplies that might be needed for that procedure, different drapes and that sort of thing.
The jargon begins here. "The nurse has to keep track of the items that are actually used and what's returned. It all needs to be accurate, and everything needs to be accounted for. If the item code number isn't pre-printed on the form, you have to write it on there along with a description."
"Document, document, document," Hudson said. "It's the mantra the hospitals have. If it's on the bill, but not in the medical record, you have to take it off the bill. If you didn't write it down, you didn't do it."
"You'll often see nurses finishing up the record in the recovery room," Cunningham said.
A data entry clerk then deciphers the handwritten surgery record and types item numbers into a billing data base, a common point where errors occur. A supervisor checks randomly for accuracy. Clerks in other departments also type in information relating to that patient. "All those claims are organized and edited by the computer, based on a program that includes all the edits that every different payer requires," Richmond said.
When the patient is ready for discharge, all his or her information flows to the coding department, where a coder evaluates it and assigns it a billing code. Then it goes to financial services, where the computer assembles it into the bill the patient sees.
Mistakes happen, Hudson said. CAMC processes 2,000 to 3,000 records a day. "We're not perfect. We make mistakes. People are welcome to come talk with us about them. Mistakes are easy to correct. That's not an issue."
Enter an auditor
Auditor Waxman said that, at first glance, he would question more than $1,000 in items on the $19,892 hospital bill for Carolyn Davis' broken leg. "If I could compare it to the medical record, I might find more." He would present them to the hospital, they might justify some, and they would go from there.
"This is a pretty routine bill," he said, with common irregularities. "After all the bills I've looked at, irregular items jump out at me," he said. "I would accept this bill for audit."
CAMC administrators won't talk about individual bills. Here are sample items Waxman would question, based on Medicare regulations:
001BLANKET HEATI $75.27"A routine supply item, a heated blanket. There should not be a charge for it."
001TOURNIQUET LE $217.07"They may be charging for a mechanical tourniquet. Should not be on the bill. If this is disposable, it's a heavy markup."
125INPATIENT SUR $3,875"This is a high operating room charge. So I would not expect to see individual items used in surgery on this bill."
003OPEN PROC BON $133.50"Open procedure. Charging a patient for both operating room time and a procedure is a no-no. That's double billing, charging for both inpatient surgery and for the procedure."
001PATIENT HELPE $141.50"I don't know what that is. It doesn't have the same code as anything else. I can't see why this patient would need a helper, with her husband in the room with her."
00114857GSB DRIL $816.00 and another 00114858GSB DRIL $816.00"Looks like it might be duplication. Why would they use two drills? Drills are reusable equipment." (CAMC since told Davis the two $816 charges are for drill bits.)
"Insurance companies don't care about small charges like the ones on this bill," Waxman said. With millions of bills, "They pass charges like this along to their customers. They look instead at length of stay and appropriateness of treatment."
Few insurance companies could afford to audit every bill, he said. "Auditing hospital bills line by line is incredibly time-consuming and expensive. It can drive you blind."
Some legislatures are taking action. By Maryland law, hospital bills must include a clear description of every item on the bill. The words "plain language" lace through Connecticut's hospital billing law.
"We want to do more in this area," said Sonia Chambers, chairwoman of the state Health Care Authority. Next year, the HCA will make life easier for West Virginians trying to decode hospital bills, she said. They will put hospital prices, charity care information, and other information on the HCA Web site.
Meanwhile, it can pay to inform yourself as a consumer, says CAMC nurse Cunningham. "If I ever have to come in for surgery, I'll be lying there telling the doctor, 'Don't use that!' And 'You can't bill me for that!' and 'If you use this instead of that, it'll cost less.'"
To contact staff writer Kate Long, use e-mail or call 348-1798.