Bamboozled: After fighting fee for phantom ‘surgery,’ patient battles ambulance double-charge

Lots of people don’t pay much attention to medical costs as long as their insurance company pays.

Not Jim Quinn.

He’s been on a mission to fight what he calls unfair charges for an August visit to the emergency room — even though his insurance covered most of the costs.

Quinn’s story comes in two parts: doctor bills from the ER visit and the cost of ambulance services.

Bamboozled wrote about his plight earlier this year.

It started when Quinn fell off his bicycle in North Caldwell.

He got himself up and moved to the side of the road, and a bystander called 911 and Quinn’s wife. She was planning to drive him to the hospital, but police wanted to call an ambulance.

“We both refused the offer to call for an ambulance,” Quinn said. “The ambulance was summoned over our objections.”

Not one ambulance, but two, arrived at the scene

Quinn said police insisted he take the ride from Atlantic Ambulance Corp., and he was transported to an emergency room.

At the hospital, Quinn said, two residents were in charge of his care and he never saw the supervising doctor. He was released with a broken right clavicle and a splint on a broken left wrist.

Quinn said he was happy with his care, but he had lots of questions about the bills.

His benefits statements from his insurer, UnitedHealthcare (UHC), included a hospital charge of $7,349, two ambulance charges totaling $3,745, and charges of $15,833 and $1,500 for an orthopedist.

Jim Quinn with his paperwork from his emergency room visit.

Nearly $30,000 in all.

In a moment, we’ll have more on why there were two ambulance bills when Quinn only took one ride.

First, though, the medical part of the bill.

Quinn questioned how the orthopedist could charge $17,333 when he never saw the doctor.

He also questioned how his splinted wrist could be called “surgery” on the bills.

“Since I did not have surgery, I expected that this was a billing error,” Quinn said at the time. “Wrong.”

The orthopedist was out of network, so Quinn received a $17,333 insurance check to cover the bills. He kept the funds in a separate account until he got to the bottom of the charges.

Quinn said during calls to the orthopedic practice and to his insurance company, everyone agreed the charges were correct.

“They defended the payment as ‘usual, customary and reasonable,'” he said. “They were not persuaded that $17,000 for looking at X-rays and concurring with the residents’ view of the diagnosis was an unreasonable charge.”

And, no one operated on him, so how could the bill say “surgery?”

While Quinn appealed the decision, he paid $3,000 from the insurance money to to stop collection threats from the orthopedist.

UHC eventually said his complaint didn’t qualify for the appeals process.

“I think the charges are outrageous and shed light on the dismal state of escalating medical costs,” Quinn said, and that’s why he contacted Bamboozled.

THE NON-SURGICAL ‘SURGERY’

We dove into what’s been confusing patients for decades: different billing codes for treatment and different pricing.

One study found wide disparities in charges at different facilities for the same procedure, while another found emergency room charges for sprains ranged from $4 to $24,110.

And not all surgical codes mean actual surgery. The code for resetting or casting a broken bone can be called “surgery,” even if no scalpel is involved.

Wanting common sense to prevail, Quinn didn’t give up.

The orthopedist didn’t take kindly to Quinn’s note, but agreed in writing to accept the $3,000 Quinn already paid. He said Quinn could return the balance of the money to the insurance company or he could pay it to the orthopedist, documents show.

The letter from UHC received by Jim Quinn, saying the orthopedist’s fee should be significantly lower.

He wrote to the orthopedist after our story ran, explaining his concerns and saying while the insurance company called the charges “customary and fair,” the charges “are not fair in any realm of reality.”

“How much time did you devote to reviewing the images of my left wrist and right clavicle?” Quinn asked in the letter. “How could that in any way justify the charge of $17,333?”

Then, Quinn received a new notification from UHC, saying the recommended charge for the orthopedist’s services should be $2,316.02.

A victory for common sense.

Quinn followed up in writing to the orthopedist in March to settle the amount Quinn now overpaid — money really due back to the insurance company.

He said he didn’t get a response, but he did receive a new bill with a balance of $14,333.

Quinn wrote to the orthopedist again, he said, but alas, no response.

So Quinn hasn’t yet returned the balance to UHC. He needs an answer from the orthopedist first.

DOUBLE-CHARGE?

Now to that ambulance bill.

When we first reported Quinn’s story, health care fraud experts saw something unusual with Quinn’s ambulance bills.

There were two charges for two different vehicles: $850 for basic life support, or BLS, and $2,395 for advanced life support, or ALS.

“Advanced life support seems excessive for a broken wrist,” an expert said, adding that Johns Hopkins defines ALS as “continuous IV medicine,” for “any patient on a cardiac monitor,” “patients with potential airway compromise,” obstetrical patients or those from urgent care centers.

“Billing ALS when BLS is more appropriate is a common scheme,” the expert said, noting she couldn’t verify what care Quinn needed. “If only one ambulance trip occurred, it is highly inappropriate to bill both ALS and BLS. It would definitely be double billing, at the least.”

But not apparently in New Jersey.

After our first story ran, Quinn said he spoke to Jim Smith, director at Atlantic Ambulance. Smith said two vehicles are required to be dispatched under New Jersey law, Quinn said.

“Quite a victory for the New Jersey lobbyists and a debacle for those in need of affordable health care,” Quinn said.

We reached out to the company.

In New Jersey, BLS ambulances are staffed with EMTs, while ALS ambulances are staffed with paramedics and carry advanced medical equipment, said Atlantic Ambulance spokesman Rob Seman.

He said only BLS units can transport patients to hospitals.

“Pursuant to N.J. regulations, the BLS unit is not permitted to provide the more advanced care, but is responsible for providing transport to the hospital,” Seman said. “The ALS unit is not permitted to transport patients and the transportation must be provided by the BLS unit.”

He said one BLS and one ALS unit would be dispatched to serious medical emergencies.

So who decides when an incident is serious enough to require both units?

A section of the state’s EMD Guidecards on how to assess the need for ALS or BLS for a fall victim.

Seman said The New Jersey State Emergency Medical Dispatch (EMD) Guidecards dictate whether one or two units are dispatched based on information provided by the person who calls 911.

“Once on the scene, the BLS and ALS crew will determine whether the level of care needed by the patient warrants the ALS Paramedics to ride in the BLS ambulance to continue providing ALS care,” Seman said, noting the ALS ambulance would then follow along to the hospital.

In Quinn’s case, it was wrongly reported that a pedestrian had been struck, Seman said.

On the scene, paramedics said Quinn had “cool, very pale, and diaphoretic skin condition” that could be a sign of shock, Seman said records showed, and paramedics called the hospital, which agreed Quinn should be brought in.

That explains the double-billing for the ambulance: the ALS paramedics rode in the BLS unit with Quinn because ALS units don’t transport patients.

Quinn disputes the diagnosis of possible shock, noting he got up, got his bike and moved to the side of the road immediately after falling.

“When the police arrived, I recognized one of the officers. He was the DARE officer for my daughter’s school 15 years ago,” Quinn said. “I mentioned this to him and that my daughter had a crush on him — 15 years ago! Does that sound like someone in shock?”

Quinn said he believes he was wrongly charged for services he didn’t want or need, and he railed against the ambulance guidelines, which he said lack  transparency and are designed to “pass along unnecessary, inappropriate and expensive medical charges.”

And it seems he will be stuck with those bills.

What do you think? Are costs for ambulance services clear? Or do you think there should be changes made? Please share your thoughts in the comments section below.

Have you been Bamboozled? Reach Karin Price Mueller at Bamboozled@NJAdvanceMedia.com. Follow her on Twitter @KPMueller. Find Bamboozled on Facebook. Mueller is also the founder of NJMoneyHelp.com. Stay informed and sign up for NJMoneyHelp.com’s weekly e-newsletter.