Seven dollars and forty cents – no sense

Seven dollars and forty cents hardly seems like an amount that should erect a barrier to health care.

In fact, when Mr. Koch (all names are fictitious) called to complain about this bill for seven dollars and forty cents, my first reaction was, “You should appreciate how lucky you are that you have a health care plan that pays most of your bills. Why are you quibbling over $7.40?”
Of course, that is not an appropriate customer service response.

But listen to Mr. Koch. “This bill is for two pain pills that were given to me when I was admitted to the hospital for an emergency surgery.   Medicare won’t pay for the pills because they were “self-administered.”

Our insurance plan won’t pay, because Medicare won’t allow payment. (a common Medicare complementary policy). The hospital wants its $7.40. I must have been semi conscious when they gave me the pills, because I do not remember it at all.  Why should I pay for pills that some nurse made me swallow when I was semi-conscious?”
Mr. Koch’s total pharmacy bill for this hospital stay was over $8,000  Who is the one who is quibbling over $7.40?  And the issue has little to do with whether the two pills cost $7.40.
In fact, it is more likely that the hospital knows full well that the two pills only cost $0.20  But they calculate that it will take at least an additional $7.20 of bureaucratic labor to collect that $0.20.  The bureaucracy needs to be fed.
Think about the effort to maintain these bureaucracies.   Somewhere in the bowels of the CMS (Center for Medicare and Medicaid Services) someone has crafted regulations that stipulate that Medicare will not pay for certain medications that are self administered.
The logic is apparent  Before Medicare Part D, CMS did not pay for prescriptions outside the hospital or physician office. “Self administered” appears to fairly delineate the boundary between those drugs that can only be administered in a hospital or physician office setting, from those dispensed by a pharmacist.

By making that distinction, CMS avoids paying for a supply of drugs dispensed in a hospital that the patient can “self-administer” at home.   That is the silo mentality.

In addition, the insurance carriers offering complementary Medicare policies have to develop claim adjudication policies and payment procedures to deal with these and similar situations.

Let’s not forget the customer service departments that have to be trained and paid to respond appropriately and effectively to complaints from other $7.40 claims.

Our office was able to determine that Mr. Koch did not need to pay the $7.40  The hospital is satisfied, because they got confirmation that they could write off the $7.40. Medicare never notices that they didn’t pay the $7.40.
So where is the $7.40?   What is the price of aggravation? Seven dollars and forty cents?


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