Some unhappy with Carle billing change

Some unhappy with Carle billing change

URBANA — Terry Maher has a tough time deciding what's more irritating: being allergic to trees, weeds, corn pollen and ragweed, or seeing her charge for allergy shot serum preparation at Carle rise from hundreds of dollars to thousands of dollars in less than a year.

Last December it was $884, and this past October it was $4,161, said Maher, 63, of Champaign. And the increase isn't just for her insurer to worry about. She has to pay 10 percent.

"I asked, 'How could it be so much more expensive now?'" she recalled.

The Carle facility where Maher goes for allergy injections was one of many in Champaign and Vermilion counties that Carle — an integrated health system with physician clinics and two hospitals in East Central Illinois — has converted to a status called "provider-based" over the past year.

Under a provider-based arrangement, a physician practice is converted to an outpatient department of a hospital, and patients begin seeing two charges — one from the doctor and one from the hospital in the form of a facility fee.

Carle spokeswoman Jennifer Hendricks said the simplest way for patients to understand the new facility fee is to think of it in broader terms as a "technical fee," billed separately from the provider charge, because it includes the cost of the facility and other technical components, such as supplies.

As the provider-based model has been expanded to physician office locations, the total out-of-pocket expense for a visit could be more, less or the same, depending on the patient's insurance plan, she said.

Provider-based billing has been explained to patients in letters, information included in bills, in individual conversations with patients and on Carle's website, Hendricks said.

But some patients receiving those higher bill combinations aren't happy about it.

Greg Hubert, 60, of Naperville, said he complained throughout the Carle system about the bills he received for services related to his daughter's cochlear implants.

Cochlear implants are small electronic devices that can provide a sense of sound to someone who is profoundly deaf or hard of hearing, and Hubert said his daughter, Nicole, needs to come to Carle about twice a year for implant programming adjustments called "mapping."

For a mapping visit at Carle in July, Hubert said he was charged a double facility fee of $420 from the hospital, along with a $480 bill from the audiologist. When he inquired about the doubled facility fee, he was told it was because the service involved both her ears.

"I was scratching my head there," he said.

Hubert wound up paying about $68 of the facility fee and about $84 of the other bill, but he pointed out his wife's company's insurer got nailed paying the rest of the charges.

"They stuck it to my wife's company," he said.

While he's disgruntled about the charges, Hubert doesn't have any complaints about his daughter's care over the last 15 years from Dr. Michael Novak, a Carle otolaryngologist and national leader in cochlear implant surgery.

But he feels Carle hasn't been fully honest with the community about provider-based billing.

"They have certainly downplayed the impact of this," he said.

He and his wife will be paying facility fees for their daughter twice a year, Hubert said, but children with new cochlear implants go for these services about a half-dozen times a year or more, "so you've just added $2,500 of added costs onto a newly implanted patient."

Maher said her allergy serum charge was billed as an outpatient service, something she couldn't understand.

When she called to inquire about that and the increase, she said someone at Carle told her "the hospital has bought the physicians, and drug companies can charge hospitals more for the same thing — and they do."

She called her insurer, HealthLink, and told them the story, Maher said.

"I said, 'You are being taken to the cleaners.'"

More complaints

Chris Johnson, 45, of Gibson City, says he encountered Carle's facility fee — for the first and, he vows, last time — when he went to a Carle convenient care center to see about a persistent cough.

His out-of-pocket expense for his visit with an advanced practice nurse was $83.75, he said. That included $20 for his doctor copayment, and $63.75 for his share of the $205 facility charge that his insurer, Health Alliance Medical Plans, didn't cover.

"Eighty-three dollars, and I needed cough medicine," he said. "I realize that may be peanuts to some people, but people are going to be afraid to go to the doctor about anything if it's going to rip a week's worth of groceries out of them."

Sherry Gillespie, 54, of Urbana, was satisfied with her care at Carle for 40 years, she said. But she doesn't want to return if she can avoid it because of the facility fees.

What happened to Gillespie: The charges for one visit to see an orthopedic doctor at Carle, who gave her pain injections in both shoulders, ran $3,326.

Her insurer allowed $2,537 of that charge — and she was responsible for paying the entire amount because of her plan deductible, she said.

Of the original charges, $1,944 was charged by the hospital for the medication and the facility, Gillespie said.

The service was pretty much the same one she'd received at Christie Clinic, where the total bill was $520 (adjusted by her insurer to $346) except she got an injection in one shoulder instead of two, she said.

When she learned she'd be getting two injections at Carle, Gillespie said, "I figured, I'll just pay a little more for this one."

More common

Carle officials declined to be interviewed further about provider-based billing for this story. But in an interview with The News-Gazette this past May, Dawn Walden, Carle's vice president of revenue cycle operations, said the switch to provider-based billing would help financially position Carle to continue providing health care for the community.

"It's a very difficult economic environment," she said. "Carle is being proactive to make sure this gem we have in the Champaign-Urbana area is providing outstanding health care for years and years to come."

Provider-based is a Medicare status that also winds up affecting non-Medicare patients because it spawns two separates fees for all patients.

Reclassifying certain areas as hospital outpatient areas can bring higher Medicare reimbursements.

And according to Carle's online explanation to patients, converting its doctor practices to provider-based status would allow Carle to apply to participate in a Medicare program that extends discounts to hospitals on some drugs for use in outpatient settings.

Provider-based billing has become an increasingly common way for hospitals to operate their outpatient facilities because they can cover for extra costs, according to the American College of Physicians.

However, the doctors' organization said it doesn't support provider-based billing for care delivered in an outpatient hospital system-owned practice when the care "is not dependent on the hospital facility and its associated technologies."

Nor should provider-based billing be used by hospitals to recoup or stabilize funding, or as a means of ensuring access to care, the organization said.

The doctors' group further maintains hospitals and hospital-owned outpatient practices "should be transparent about their billing policies with patients prior to providing care, particularly if the patient and/or their health plan will be responsible for both physician service and hospital facility fees."

Hendricks encouraged patients who still have questions about provider-based billing and facility fees to call Carle at 888-712-2753.

"We always encourage people to talk to us when they don't understand their bills," Hendricks said.

Sticker shock

Though unpopular with many patients, Carle's conversion to provider-based billing has been taking place gradually over the past year:

— Carle first converted its cancer center and radiology department in December 2012.

— Earlier this year, Carle added all physician offices in its north and south clinics in Urbana (except the oral and maxillofacial surgery department), along with the south clinic lab, cardiology services and maternal fetal medicine and sonography.

— Also transitioned: the digestive health center; the Expanding Children's Hearing Opportunities program; the physician offices in Mahomet, Monticello and Rantoul; the Carle Spine Institute; Carle's north annex and the physician clinics on Curtis Road, Kirby Avenue and Mattis Avenue in Champaign and Windsor Road in Urbana.

— The latest to be added: Carle's physician offices on North Vermilion in Danville and part of its facility on Fairchild in Danville — the occupational medicine, lab and radiology service.

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Trailmom wrote on December 17, 2013 at 10:12 am

So, why run this story now?  There is no new information. Or was this just an opportunity to make a plug for a new venture as pointed out by John@news-gazette? Seems pretty self-serving.

Odd, the post by John@newsgazette was deleted.   Hmmmm....


Lostinspace wrote on December 17, 2013 at 11:12 am

"Some" people are unhappy?  Isn't everyone unhappy?  Where is the outrage?  Insurance payouts without price controls?

"[O]ut-of-pocket expense for a visit could be more, less or the same"?  Are they counting insurance rates?


BlahBlahBlah2013 wrote on December 17, 2013 at 5:12 pm

"[O]ut-of-pocket expense for a visit could be more, less or the same"?  Are they counting insurance rates?

This is corporate speak so let me translate, if I may:

"90% of all Carle patients will get screwed by a facility charge. Because that percentage is not 100% we will publicly say that some visits will be the same or less. That way we technically aren't lying."

Hope that helps.


Lostinspace wrote on December 17, 2013 at 6:12 pm

It helps.

The point is that we are *all* paying out of pocket for increased health insurance.  If Carle is gouging the insurance companies, we in turn are gouging our healthy neighbors each time we go to Carle.

Not only that: I used mycarle to make an appointment for an annual physical (necessary if I wish to renew prescriptions) with my primary care provider.  I am given an appointment in a "no-reply" message.  When I check mycarle, I find I have been given an appointment with a nurse.

I can of course call and change the appointment (for a much later date); I should have avoided mycarle in the first place and made an appointment as usual.

So: use those "facility fees" (by the way, who paid for the facilities before the fees were imposed?) to hire some general practitioners, if you can find any who would want to work for such an organization.

BlahBlahBlah2013 wrote on December 18, 2013 at 8:12 am

Great question! "Who paid for the facilities before the fees were imposed?" Long story short, probably Medicare indirectly. Medicare has been cutting reimbursements so Carle had to look elsewhere to make up that shortfall. So who better to collect from than its patient's pockets who can least afford it?

What always disappoints me the most isn't even the fact that they are operating in a very greedy and manipulative fashion but, as the person in the article said, they downplay the whole thing. They say, "some will be affected", which is complete BS. They know it's BS but they say it anyway.


LocalTownie wrote on December 17, 2013 at 12:12 pm

Hmm, Christie Clinic doesn't have all these extra BS charges. I think I'll switch!

BlahBlahBlah2013 wrote on December 17, 2013 at 5:12 pm

Hopefully Christie Clinic will not fall victim to the greed and manipulative practices of Carle. I'm with you though, I'm going to Christie.

BlahBlahBlah2013 wrote on December 17, 2013 at 5:12 pm

Random Thoughts:

1) Oil companies....Carle....not sure which is #1 on the most hated list but they are both greedy, manipulative and self-serving.

2) This is nothing more than a billing loophole/scam that Carle uses to try and recoup cuts in other areas. Carle won't get stuck with the shortfall...their patients will. Congratulations. You've just been screwed!

3) Carle doesn't pay property taxes, double bills a large percentage of their patients, and then builds a $300 million "gem" of a building. Hypocrites. Don't cry about not having any money.

4) Jennifer Hendricks is drinking the Carle Kool-Aid too, along with the administration at Carle. I wonder what flavor she likes most?

5) Dawn Walden...please. Spoken like a true Carle VP. Where do they get these people? Church? They sound like they are in a cult. Drinking the Jim Jones Kool-Aid.

6) Last time I went to the doctor I went to Christie Clinic. First time in my 46 years in this area. I won't go back to Carle and it's mostly because they are gouging me and every other patient that walk through their doors.

7) Dont' be afraid to change clinics. We have a choice here in CU. Carle looks nicer, sure. That's where all your money goes. But their doctors are no better or worse than the docs across town. It's just that they charge more. Make the move. I did. 




Krystufer wrote on December 17, 2013 at 7:12 pm

The same thing happened to my wife...we are new to the area and she was setting up primary care but never once informed her of the physicians group billing was seperate not to mentioned not covered by our insurance however good news the facility was covered!!! Hoorah....$800 out of pocket later is a joke. This was after we called carle and asked if we are covered and called our insurance to verify with the answer from both yes...

Needless to say I am a manager at a major retailer and will let everyone know about this terrible business. In addition myself nor my family will ever go back to their facilities. I will preach this for the rest of my life.

BlahBlahBlah2013 wrote on December 18, 2013 at 8:12 am

Krystufer....welcome to Champaign-Urbana! Lol. I applaud you for taking your family elsewhere for care. Carle has the potential to be great. The potential. If you ask the people at Carle, they'll tell you they ARE great. In reality, they have a long way to go.


rivardau wrote on December 19, 2013 at 3:12 pm

Well, this explains a lot.  And I'll agree with other commentors, it is a Carle scam!
 Albeit, legal it seems, as they get paid when they do it....

My only interaction with Carle is for dermotology, at Curtis/Mattis.

A plain office visit.  No supplies used, no medications given at the facility, and same doctor I have seen for over 2 yrs.

My annual October visit, mainly for a quick exam and to get skin prescriptions sent to Walmart for another year, and the same thing I had done previously, this time in 2013 had 2 bills, one for the doctor, and one for the facility.  in 2012, there was only 1 bill.

Even though I have been an established patient, I *never* got any word that this was a change.  Not in advance in the email, I didnt have any billing bcs my account was paid in full already for previous appointments, and no one at the facility on the day I checked in said anything or handed me a paper or nothing.

so, looking at my xlsx data...

FALL 2013 - dr charge was 93.00, but contract adjustment off 44.01, leaving allowed charge at 48.99.  my ins paid 8.99, leaving me a bal of 40, which is my copay for a specialist visit that is correct and ok.

there was a new line item for carle facility charge, was 205.00, but contract adjustment off 156.97, leaving allowed charge at 48.03.  my ins paid the full amount of 48.03, leaving me a bal of Zero.   so this is ok in my case, bcs i am paying zero, but my ins is paying 48$

their total billings was 298, they got paid by my ins of 57.02, and i paid 40. 

they had grand adjustments off of 200.98, and were paid grand total of 97.02.

SUMMER 2012 - dr charge was 125.00 (higher), but contract adjustment off of 67.14, leaving allowed charge at 57.86.  my ins paid 17.88, leaving me a bal of 40, which is my copay for a specialist visit that is correct and ok.

their total billings were 125, they got paid by my ins 17.88, and i paid 40.

they had grand adjustment off of 67.14, and were paid a grand total of 57.88.

net results, the doctor charge went down, but added a massive new facility charge.  even though they had to discount 200ish $ off, the grand total payments they received in 2013 were 97.02, while in 2012 they only received 57.88.

While i kept the same plan both years, and my co pays were the same for both years, Carle was able to gain a net increase of revenue of 39.14, which was a 40% increase in revenue (i believe, someone can double check the math as im not good at %age).

whether good or bad, that is an opinion.  However, I did the same things both years, the established patient status was the same, the doctor did the same, which was simple office visit and sending prescripts to walmart, no other supplies or facilities were used differently, and my insurance stayed the same.

the only thing that changed was carle's billing system, and they can increase their revenue.

fortunately, my personal funds stayed the same, but that is because of MY insurance.

I can definitely see how people who have different insurance, or *GASP* none at all, would definitely be made much worse off.

And if these actions are increasing patients' bills by 40% OR MORE, then of course patients who have to pay full cost will get less care, thus spreading their sicknesses or bacteria around more and affecting me and others in the community worse.

So, why, again, are we allowing these "facility" charges as separate line items when nothing is different from one appointment time in 2012 to one in 2013?

If supplies such as medicines, bandaids/cotton, whatever are used, then i can see those being charged, but as itemised line items.  but an entire 200+ $ generic facility fee? 

I will disagree with Carle's practice, as well as the federal laws that allow it..


pattis69 wrote on August 14, 2014 at 5:08 am

I receive a letter from Mills Breast Clinic each October to remind me that my annual breast exam is due. In past years, I called the Breast Clinic and set up the appointment. In October 2013, I received the letter, called for my appointment and was told that I would have to see my primary physician first before I could schedule my mammogram. I did as instructed and made the appointment for October 8, 2013.. I asked my primary why the visit was necessary and she stated that the clinic wanted to be assured that I was healthy enough to have the mammogram performed. She did a preliminary exam, told me that I needed a tetanus and pertussin booster and sent me on my way. In January 2014 I received a bill for that visit in the amount of $78.00 even though I have Medicre Part B and a Medicare Gap insurance that pays 100% of what Medicare doesn't pay. My primary physician had coded the visit as  "preventative", therefore, neither Medicare Part B or my gap insurance would pay. I was not notified by the Breast Clinic or my primary physician that I would be charged for the visit. I want to notify other women who are contemplating a mammogram that they will have to pay for the required visit to their primary physicians before they can have a mammogram. I have now made the decision that I will not undergo my annual mammogram because of the changes in Carle's policiy. I live on SS and I pay an exorbitant amount each month so that I will not be surprised by unexpected invoices for doctor visits. I feel this practice in unfair. Notify the patient that they will be charged for the preventative visit and let them make the decision if they want to schedule a mammogram.