Defrauding HMOs

This was my column yesterday, July 2.

Do hospitals deliberately pad the medical bills of patients who avail of hospitalization using their Health Maintenance Organization cards?

I expect a surfeit of righteous indignation and an avalanche of denials from hospitals and medical practitioners. They are welcome to show proof that this is not happening and I would be very happy to be proven wrong. Unfortunately for them, I am speaking from experience. And as we all know, a man with an experience is never ever at the mercy of a man with an argument.

This issue has been whispered about for quite some time now except that as far as we know, no one has come forward to actually make a direct accusation. Most everyone I know who has been hospitalized and who used a health card had a story to tell about how he or she has been charged extra for medicine or medical procedures that were not actually given or performed on him/ her. There’s always an excess vial of drug, an additional bedpan, or whatever else inserted into the bill.

Just this year, a friend who was hospitalized for a serious condition told me that when she checked her bill prior to being discharged, she noted that the drug dosages reflected in her bill were overstated. It was only when she complained that the hospital made the necessary correction. She wondered what would have happened if she did not check her bill. And to think she only bothered because she wanted to ensure that the balance in her HMO limit would be enough to cover the cost of follow-through medication and treatment.

The same situation happened to an officemate who was confined early this year in another hospital. Like I said, this issue of padded bills particularly when one is using HMO cards had been cropping up more regularly lately and had been the topic of hushed discussions in many circles.

Thus, many among us in the human resource management profession have taken to advising employees who avail of medical benefits using their HMO cards to check and recheck their medical bills before being discharged from a hospital. We know that very few actually do.

To begin with, understanding medical bills is almost as arduous as reading a doctor’s prescription. It requires some knowledge about drug dosages, medical procedures, etc.

In addition, unless one underwent a really terrible experience while being treated, it is difficult to turn around and accuse one’s healers of corruption. One does not want to come across as ungrateful to the very people who saved one’s life. Besides, fraud is farthest from one’s mind at a time when one just wants to go home and escape the antiseptic smell and claustrophobic ambience of hospitals. One just simply wants to get out of there.

If one were paying for the bill, going through it with a sieve and a fine-toothed comb would be expected. But HMO cards free cardholders from having to shell out money for their hospitalization needs. And when the medical bill does not make a major dent on the card benefit limits, checking every single item in the bill just seems like a tedious and unnecessary process. Very few do it. The attitude is “I’m not paying for it anyway.” Or worse, “It is about time HMOs pay up since they earn so much from all those unused premia.”

Whether HMOs make profits or lose money is irrelevant. It is a business. More importantly, it is in the insurance business. Thus, some make money and some don’t. Some lose money on a particular year and then make a killing on another year.

But it is wrong to assume that increased utilization of medical benefits through HMOs do not eventually have an impact on employee cardholders or on the companies who pay for the premiums. Any increase in utilization automatically raises the premium in the succeeding year. And more importantly, any utilization reduces one’s personal medical benefits under the plan so the available balance for succeeding treatments become less and less. The possibility that one eventually pays up for medical costs beyond the prescribed limit becomes higher.
Let me now share the personal experience that triggered this piece. I was hospitalized last week (yes, again, and I am praying hard it would be the last in a while) and underwent emergency surgery for an infection. Part of the treatment regimen was heavy doses of antibiotics.

I was cleared for discharge Thursday evening so we expected our bills to be processed early morning of Friday so we could leave before the cut-off time and avoid being charged another day for room and board. I was prepped up, dressed, and ready to go at 8 a.m. By 9 a.m., the nurses said the papers would be ready in a few minutes. By 10 a.m., my sister could no longer bear the waiting time and decided to take matters into her hands.

She marched into the billing section and demanded to be shown the final bill. Because my sister happened to be a nurse, she decided to check the bill. To her horror, she discovered that the total dosage of antibiotics that was supposed to have been pumped into my body, and which was being charged to my HMO, was three times more than what an ordinary mortal would be able to take. It was either of two things. Either there was an overdose or there was something wrong with the bill.

The hospital people initially insisted on the veracity of the dosages. But when my sister revealed that she was a nurse and insisted that there was no way anybody would be able to tolerate triple the maximum dosage of higher generation antibiotics for four days, that’s when they decided to check.

It turns out the bill was padded with seven additional vials of antibiotics, each vial costing almost P3,000. That comes to about P21,000. And that was just the antibiotics. There were other things on the list including urinals and other supplies that were not used. The mini uproar over the bill delayed my discharge to 11 a.m. To add insult to injury, the hospital had the temerity to still charge me an additional half-day room and board.

During the whole dispute over the bill, the nurses and the administrative clerks kept on reminding us that I was using a HMO card and that I was not going to shell out any amount from my own pocket. At one point, the billing clerk actually asked my sister directly why she was being so punctilious about the items in the bill when my HMO was paying for it anyway. I had to call my HMO and ask them to intervene.

It is possible that what happened to me was a fluke. The hospital would most likely put the blame on the nurses and accuse them of negligence in the performance of their duties, particularly in ordering and accounting for medicine, or in documenting usage of medical supplies and procedures. But my gut feel says otherwise. I have the feeling that there is institutional and systemic carelessness when it comes to charging medical costs to HMOs.