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.

"How forceable are right words," says the Bible in Job 6:25.

Byzantine language packs a wallop too. Bewildering hospital paperwork, unclear language and multiple billings greatly aggravate the problems (and stress level) of anyone who tries to contend with a major medical bill.

In spring 2003, Brandeis University's Hospital Access Project published "The Consequences of Medical Debt," a three-community study of the devastating impact of medical bills on low-income people. "On top of dealing with the sheer magnitude of their debt, many are challenged to understand the sources of their debt as well as to whom they owe and why," the report's authors wrote.

Unclear language also keeps people from spotting errors. "When held up to scrutiny, almost all hospital bills contain errors," according to Chicago's Hospital Accountability Project. But it is hard to scrutinize a bill you can't understand.

First, get an itemized bill, consumer advocates advise. The first bill the hospital sends you may not tell you much. Carolyn Davis' first bill, for instance, read: Room & Board — Semi-Prvt $1,149.00. Hospital Incidentals $18,219.72."

Davis spent four days in Charleston Area Medical Center in May after she broke her leg.

She wrote CAMC and asked for an itemized bill to clarify that $18,219.72 for "Hospital Incidentals." Her husband, Roy, pored over it after it came. "If I can't understand this stuff, what chance does the average person have?" he asked. Before he retired, he scrutinized thousands of bills a year as construction supervisor for Union Carbide, worldwide.

Here's a sample. What do you think they are?

001LEVEL 5 $993.50

002PACK SHEET SP $95.48

00214857GSB SCRE $1,564.00

00114857GSB NAIL $1,755.00

00114857GSB DRIL $816.00

After three visits to CAMC, Davis said, billing staff was still saying they didn't know what some items on his wife's bill were. So he and his wife visited her surgeon, who told them the NAIL is a titanium rod he put in her leg, the END is the cap on the NAIL, and the SCRE are screws to hold the nail in place.

"Why can't they tell you that to begin with?" Davis said.

Many hospital billing employees really don't know what the items are, said Edward Waxman, president of Waxman & Associates, a York, Pa., firm that audits bills nationwide. "They see the terms every day, but may never have seen the objects the terms represent," he said. They handle verbal widgets on the billing assembly line, he said.

'We are trying hard'

"I sympathize with the patients trying to figure out their bills," said CAMC Chief Financial Officer, Larry Hudson. "We are trying hard to make our billing more patient-friendly." CAMC has contracted with an outside firm to do so, he said. Their new computer system will streamline the billing process, he said.

Will they rewrite the bill language so people can understand it? He looked surprised. "There are more than 20,000 items on our charge master," he explained. "It would be a huge task. And there's no plain-English substitute for much of the language, particularly relating to prescription drugs." Government programs require medical language to process the bills, he said.

"And most customers never see the itemization," he added. He's right. Seventy percent of CAMC's customers are covered by government insurance, paid through diagnosis codes, without itemized bills. And many privately insured people assume their insurance company checks for errors, so they don't ask for itemized bills.

Insurance companies review very few bills for errors, Waxman said. "For the most part, if you don't want to pay for things you didn't receive, it's up to you to check the bill or have it checked," he said.

Uninsured people — self-pay customers, hospital administrators call them — are between only 3 percent and 5 percent of CAMC's customers, said Jay Richmond, director of Patient Accounts. But small amounts of money are critical to those people. An audit of an itemized bill can save crucial money for an uninsured person with a monthly food budget of $100, especially given the fact that uninsured people are charged top hospital rates.

Translating into jargon

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.