Some unhappy with Carle billing change


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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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