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hello this is dr eric bricker and thank you for watching a healthcare z today's topic is abusive billing specifically around radiology reading fees now abusive billing is the a in fwa fraud waste and abuse and so fraud is like you know billing for medical services like that never happened waste would be like billing for things that like were totally not necessary but what's abusive billing i mean that's just kind of a nebulous term so this is actually a really good example of abusive billing and you can and we can see how it impacts an employee health plan okay so this is an extension of the story of my wife's mri where the previous video that i made was talking about the facility fee for the mri but the mri also has a professional fee for the radiologist to actually read it so that's called professional fee vis-a-vis the facility fee which is for where it's done now the professional fee 480 a loud amount for an extra you know for like a chest x-ray it's like 15 and typically the the fee might max out like 150 right the build charges for the for the just reading which takes like five minutes for reading the mri was four hundred fifty three dollars so we get this i'm like that doesn't sound right my wife goes ahead and she calls into the billing office which of course by the way they had outsourced their billing to a company in california now keep in mind we're self-pay because we don't use traditional insurance and we use a faith-based medical sharing plan again another video for another day but we're working with no insurance network here okay that's fine we kind of expect that okay i still wasn't expecting 4 400 for build charges okay so the outsourced billing company in california which my wife has to be on hold for an hour for says okay we're authorized to give you a 50 discount okay great so we would still have to pay 2 200 for a five minute reading of an mri i'm like it's still something something's messed up that's like facility fees like facility fees for mris even on the high end or 2200 never the reading fee okay so i call the radiology practice kind of complicated phone tree i kind of just had to guess on a number and left the message and then somebody else who wasn't even the person i left the message for called me back and said okay well i can actually give you up to an 80 discount off those bill charges of um 800 so that 80 of the 453 gets you to 891 and i said look that 44.53 for bill charges that there's something wrong there that's that's that that can't be right and she said oh no that's right that's what we built from blue cross united cigna medicare we built all those companies 44-53 i'm like whoa i need to talk to your boss because that does not sound right and of course she was highly reluctant to do that but i'm just like listen i'll talk to the ceo the cfo i mean this is i i pulled the doctor card i said look i'm a local internist i know a lot of radiologists i would appreciate more of an explanation than what you're giving me she said okay i'm gonna have somebody call so the next day um which oh by the way medicare reimburses the radiology read on this mri 118 and i called around to some other folks for some references so in illinois bill charges for this mri are 894 as opposed to 4 400. and in florida they're 466 dollars as opposed to 4400 so in florida the build charges uh are a tenth of what they were trying to bill us for okay so i talked to the director of accounting she calls me back she's very apologetic she's like look the bill charges they were an error uh we actually did some changes to our cpt codes and we combined multiple build charges to that one cpt code where we really shouldn't have and she said and we and we did it in 2019. so this has been going on for over a year they had not been aware of it and she was like thankful that i brought this to her attention because they needed to go back and change it because that obviously wasn't right but keep in mind this has been going on for over a year that they've been doing this and then she said something very interesting she says what we do is we actually aim for about 10 times medicare for our billed charges because we still have percent discount contracts with some of our insurance carriers aha that is unique so percent discount charge means that okay so 10 times medicare is still billing 1180 which is still higher than illinois or florida by a long shot and then the insurance carrier reimburses them like a 50 discount off of or maybe even a 60 discount off of bill charges so that means the insurance company is still paying upwards of 400 to 500 for a five minute read of an mri and so listen most mri contracts are not that way in fact my wife had a previous mri back when we had blue cross and the allowed amount is a it's a fixed case rate of 188 dollars so and that's like for an office visit for office visits it's it's basically the same thing right if you go in for an office visit it's going to be a fixed amount for a certain level of intensity of the office visit okay so basically but not all their contracts are like that some of them are percent discount so what does that incentivize the physician practice to do to raise their build charges as much as possible because if they are getting reimbursed 50 of bill charges then what's to stop them from increasing their bill charges from 500 to a thousand to 2000 to 453 dollars the more they raise the bill charges the more they get paid now this is particularly interesting because when i bring up percent of of of charge discount contracts this is when a lot of carrier reps come back to me be like we hardly do that anymore that's a really old contracting methodology we really don't do that everything is pretty much at a fixed case rate these days and i'm like okay well that's that's not what i'm that that's not my understanding on the provider side and here we have another example of a radiology group that is intentionally jacking up their bill charges to 10 times the medicare rate so they can maximize reimbursement from insurance companies that have percentage charge discounts and on top of that they messed it up and they quadrupled their billed charges over a year ago so fine she says look i'm sorry for the you know for the inconvenience thank you for bringing this our attention i'm just going to give you the medicare rate of 118 so i pulled out my credit card paid with the credit card over the phone and we were done for 118 dollars instead of 4 453 okay but this gets to the abusive billing did she go back and for all of those mri claims that they built out since 2019 for the 4453 if it was to like blue cross at a fixed case rate of 188 it wouldn't matter they would just have to uh to discount it down that amount but for all those insurance carriers where they have a percent of charge discount then that radiology group is potentially getting paid 2 200 for every minute for every five minute read of an mri now that was abusive billing it was a mistake on their part but that was abusability that was abusive build charges now the the tpa or the aso carrier guarantee they didn't catch it why because their claims uh review threshold is typically around five thousand or ten thousand dollars so squeaking in at 44.53 no person would have ever seen this claim it would have been auto adjudicated and auto paid and so for the last year employers whether they be self-funded and fully insured have been paying you know upwards of twenty two hundred dollars for mri reads for this particular radiology group in error and this is just one happenstance that our family happened to run into so how many other physician practices have percent of charge discounts where their billed charges either on purpose or by accident are upwards of 40 times medicare and if you are getting a 50 discount off of that you're still paying 20 times medicare then i would argue that falls into the a of fwa of fraud waste and abuse so just know that this is probably happening to your plan and unless you're getting detailed claims reports and you have people with the expertise and the time to go through which there there are people that do this then you know it's likely that you're missing this stuff and you're just paying out stuff that you shouldn't and that's my point for today thank you for watching the healthcare scene