Additional Hospital Bill *Confused*

[u/dunderthecovers]

Hi all,

Forgive me, as I am having trouble wrapping my head around this one. I am covered by Anthem Blue Shield and went to Mount Sinai in NYC to have my leg looked at from a knee injury. Two visits. Each time they charged me $75 at the physician's office and said that's all I would need to cover and Anthem would do the rest. A few weeks later and I am now getting billed an additional $360 per visit. I called Mount Sinai and they said this is an "outpatient facility charge" which is separate from the physician's office charge. Is this normal? I was under the impression my insurance would cover the rest of my visit. If anyone recognizes this and can clear it up for me I would gladly appreciate it! (screenshot of the bill summary is attached).

[u/voodoobunny999]

There’s a lot of confusion in the replies. I’ll try to sort this out so it’s understandable. First, there are a few bills you could see: (1) Fee for professional services provided by the doc who looked at your knee (reimbursement for the doc’s time for exam, staple removal, maybe reading xray, etc.), (2) Fee for the clinic, which is a dedicated area or department that provides outpatient care, meaning patients receive medical services without needing to stay overnight in the hospital (this includes reimbursement for overhead like staff, supplies, equipment, etc.) (3) Fee for the technical part of your x-ray (essentially reimbursing the hospital for taking the x-ray, maintaining the equipment, xray technologist wages, etc.), and (4) Fee for a radiologist to read the x-ray and provide a report to your doc in (1).

Based on the documents you’ve shown, it doesn’t appear that you’ve been billed for the x-ray or the Radiologist. If your doc did the xray and read it himself, those charges are likely included in the bill for his services. If not, you might still get up to 2 more bills. Whether you will owe anything for them is a function your health insurance benefit plan.

Other folks have responded talking about a ‘facility fee’, but that term is confusing in this context. What they are talking about is a ‘clinic fee’ which is a charge to reimburse the hospital for (essentially) the doctors’ offices they provide.

I believe the origin of these charges stems from when hospitals put clinics into neighborhoods near the hospitals. The purpose was to make low-acuity care readily available and to serve as ‘feeders’ to the hospital for higher acuity problems. There was no doubt that hospitals were entitled to enhanced reimbursement for building these clinics, hence the Clinic charge.

Over time, the meaning of ‘clinic’ morphed. A clinic might be 5 miles away from its parent hospital, but it also might be on the hospital’s campus—just a separate building. Can you justify reimbursement for one but not the other?

Some health insurers tried and some of them were successful. Others weren’t able to hold the line even when clinics were established inside the hospital itself. In time, patients didn’t realize it, but they weren’t visiting the hospital for Jimmy’s ear infection, they were visiting the Pediatric Otolaryngology Clinic within the hospital.

You went to a clinic at Mt Sinai and they’re billing you for it. It’s separate from the charge for the physician’s time and effort.

Now, just for the sake of completeness, allow me to bore you with what ‘facility fee’ really means. First, it only comes in to play for physician services provided to Medicare patients OR for commercially insured patients whose insurer has negotiated a contract with a physician based on Medicare reimbursement.

So, let’s say, for the sake of argument, that you’re a Medicare patient and you have a large, unsightly mole on your face. You visit the Dermatologist and he might be able to remove the mole in his office, but because it’s so large and visible, he might prefer to do this at a hospital he has privileges at, so he has more resources at his disposal.

Your Derm’s choice whether to perform the surgery in his office or at the hospital affects what reimbursement he will receive for his services. If he performs the service at the hospital, he will receive the Medicare ‘facility fee’ for his professional services (confusing, I know), because he performed the surgery at a ‘facility’ (hospital, for our purposes). If, instead, he removes the mole in his office, he will receive the Medicare ‘non-facility fee’ for his services, since he didn’t perform the surgery at a facility.

For every procedure that I can think of that can be performed in a doctor’s office OR in a hospital, the reimbursement for the physician is at least as high (and almost always higher) for performing the surgery in his office, rather than in hospital. Surprised? It’s because when he performs the surgery in his office, he needs to be reimbursed for overhead (rent, staff, etc.), whereas we he performs it in hospital, he doesn’t have those costs.

Two last twists: (1) Just because the doc gets paid less for performing the surgery in hospital doesn’t mean you (and/or Medicare or your insurer) pay less, since the hospital will also be sending a bill for the use of its staff, operating room, clinic space—whatever—that wouldn’t be incurred in an office procedure, and (2) Your doctor isn’t making the determination to perform your procedure in office or in hospital based on Medicare reimbursement.

My apologies for being long-winded and for using male pronouns to refer to doctors. There are now more women in medical school than men and there will soon be more in practice, as well.