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March 29, 1992|PAUL LIEBERMAN

It seemed the perfect place to take a grand flop on one's back--right there in a hospital, right in front of a nurses' station, in fact.

I was walking down a corridor, heading for the room of my father, when I encountered an unseen puddle of who-knows-what liquid, apparently spilled moments before. My feet flew out from under me, precipitating an acrobatic half-gainer worthy of a comic circus act. Several nurses hurried to my aid and, despite my protests that I seemed OK, insisted on rushing me to the emergency room for a checkup.

"Just do one thing first," I implored, making a request based on long experience. Before a single test was begun, I said, they needed to write two words on the medical forms: HOSPITAL PAYS.

So it was done, and I hardly gave a second thought to the quip of an emergency room supervisor, "Anything to get you in the clutches of our billing department."

Two weeks later, it wasn't a joke. That's when the bills started arriving, one for $185 from the hospital and another from the radiologist who spent all of two minutes inspecting the X-rays of my back. He wanted $60.

I responded with an indignant letter recapitulating the outrageous events--and billing the hospital 29 cents for the stamp.

The result? Threats began arriving from a collection agency.

As my blood pressure zoomed into the red zone, my thoughts drifted to the film "The Hospital," perhaps the most biting parody ever made of the American medical system. It suggested that appropriate justice for a crew of arrogant doctors was to have them become, suddenly, anonymously--and eventually fatally--patients in their own institution.

It seemed to me, at this moment, that those doctors had been let off too easy. My own lifelong string of encounters suggested a sentence worse than death. Someone should simply have sent their names to the &$%?!&% BILLING OFFICE.

I made my maiden voyage into this "Twilight Zone" two decades ago, when medical costs still seemed irrelevant to my own young life. One Monday morning, the managing editor of my newspaper back East called me aside to request "a special, highly sensitive investigation." Naive in many ways, I assumed he was talking about an important story. "Not quite," he said. "The publisher needs some help."

The publisher's son, it seems, had fallen off his bicycle, struck his head and suffered a concussion. He'd been taken to a neurologist. Now there was confusion about the bill--the insurance reimbursement, in particular.

"What am I supposed to do?" I asked. "Write something or help the boss man save money?"

The editor shrugged. "Just see what's there," he said. "Hey, it's his sandbox"--this referring to the newspaper--"he can play in it any way he wants."

The next day, I was off to see the neurologist.

He wanted help too, it turned out. He could understand the human brain, no problem, had board certification to prove it. But insurance was "a complete mystery to me," he said. Then he tossed three years worth of files on a desk.

His confusion centered on the way Blue Shield--the major insurer for that Eastern state, covering 4 million people--paid for his most basic service, a neurological consultation. Sometimes it reimbursed the patient $32, other times $21. Same coverage, same exam, same doctor. How could that be?

Two days later, I visited the headquarters of Blue Shield to find out. The insurance company, confident there was no problem, opened its records for me, massive stacks of them. But, lo and behold, it was true: 54% of the patients got the lower payment for the neurological exam--incorrectly.

"We have got a problem," a company official declared.

We eventually determined that it all came down to codes. Rows of clerks ("adjudicators" was their official job title) at the insurance company pored through the forms submitted by doctors, jotting in code numbers to determine the payment for each service. Often, however, they wrote in the code for a neurological exam by a non-specialist when a specialist had provided the service, meaning the lower payment. Other times, they assumed it had been a cursory checkup, not a complete neurological exam, again meaning the lesser amount.

"The key is the word complete ," the company official said, complaining that physicians often didn't include that magic word in describing their service.

"There are hundreds of procedures," he said, "where the difference in one word (on the insurance form) makes a difference in the amount."

Indeed, records for two other procedures--spinal taps and the removal of lesions on the face--similarly revealed widespread underpayments because of how clerks interpreted the doctors' wording.

In this case, there was a happy ending. I got a story, after all. The insurance company clarified its procedures. Most importantly, the publisher got his extra $11.

But the experience provided a sobering lesson: The doctors had been well meaning. The insurance company had been well meaning. And the patients were getting screwed.

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