Lesson Of The $446 Ear Rinse: Medical Bills That Make You Say 'What?!'

THIS COMMUNICATION IS FROM A DEBT COLLECTOR. THIS IS AN ATTEMPT TO COLLECT A DEBT.  ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.

Get your attention, all those upper-case, bold-face letters? They certainly got mine, when they came in the mail recently. It was a virginity-losing moment: My first debt-collection letter in more than a half century of financial clean living.

And of course, it was a medical bill that did it — just as it's medical care that causes more American personal bankruptcies than any other bills.

My health bills for preventive care had all seemed reasonable until now — or at least, they were bountifully paid by insurance. Mammograms, children's check-ups, all were fully covered. But I'd shifted recently to an insurance plan with a $500 personal deductible, and I'd made a naive mistake: When my doctor kindly offered to clean my waxy ears during my annual check-up last April, I said, "Okay..."

Well, really, how was I to suspect that three or four minutes of whooshing ear-rinse could add up to $446 out of my pocket? (Correction: $446 upon first billing, but knocked down to $338.03 after several long and tortured phone calls, and a medical re-coding. It still struck me as insane, but I paid it to get the collection agency off my back.)

Doctor, if we're going to cross the line from preventive to billable, I’d like you to let me know.

It's an ever-more-common American rite of passage: That shocking moment when you unfold the bill, look at the total that is unpaid by your health insurance, and expostulate, "Are you (expletive) kidding me?!?"

Readers, do you have an eye-popping bill and back-story you'd like to share? We're hoping to make this a series — "Medical Bills That Make You Go 'What??!'" You can send in your story — and, if you'd like, scans of your bills that will protect your privacy — by clicking on the "Get In Touch" button at the bottom of this page. Goodness knows, you have few other outlets for your frustration.

In my own case, I'm asking you to brave the numbing tedium of any billing tale because there's a clear object lesson here: Yes, preventive care, including check-ups, must be fully covered by insurance plans under Obamacare. But that doesn't mean that everything that's done during a check-up has to be covered.

And therein lies the rub. The line between "preventive" and "diagnostic" or "procedural" can creep up on you, as WBUR's Martha Bebinger has reported: When Is Preventive Care Free And When Do You Pay? Her report included this valuable lesson: As one Massachusetts woman was horrified to discover, it’s possible to go in for a free — because it’s preventive — colonoscopy, but then, while you’re still on the table, if the doctor finds polyps and removes them, that transforms it into a non-preventive — and thus potentially billable to you — “surgical procedure.”

I'd read that story but clearly I didn't take its lesson enough to heart. I also take full blame for my longtime practice of getting routine primary care at an expensive top Boston hospital: You can see in the upper right corner of the image above that the initial charge to my insurer for my check-up — which involved no lab tests and nothing higher-tech than a blood pressure cuff — was nearly $1,192.

Still, in hopes that my own financial pain might help others, I asked Blue Cross/Blue Shield of Massachusetts, the biggest health insurer in the state and the one that happens to cover me, for useful pointers. I spoke with Debra Wilson, a senior manager in the Member Service Division. Our conversation, lightly edited:

DW: I think it's great that you're highlighting this for people. Folks go in and have preventative visits, and things will invariably come up. The patient is there and having their physical, but they're also addressing problems. These problems could be longstanding. So it's important that when something does come up and present itself, that the patient ask questions.

It's very important that all of us are educated in our health care decisions, and part of that is that we not be afraid to ask, 'What does that entail and what might the cost be?'

Ask questions beforehand so you're fully aware of what's going to be involved, not only with the procedure but the cost. It can generate a liability to the patient, and no one likes an unplanned bill. We've also asked our network management team, the folks in the field working with physicians' offices, if they could also educate the patient at the time — usually after the fact, but let them know, if they were in for a visit and also had a procedure or additional service, that they could receive a balance bill.

We don't want to discourage these conversations with physicians because it's probably something they do need to have addressed, and it's being done all in one trip, so it's efficient. We just want everyone to be aware of what could happen in terms of cost liability, that that could change depending on services rendered.

The tricky part for the patient is that it can be hard to know whether something is considered preventative or diagnostic or a procedure. For example, at that same checkup of mine, my doctor found that my blood pressure was a bit elevated, so we discussed ways to lower it. Conceivably, that could be billed as not preventive but diagnostic, or an education procedure?

That's discretionary, based on that particular provider's office and their billing practices. Certainly, that could be within the preventative visit, but again, I think it's important not to be afraid to ask those questions.

Would it be reasonable to go into a preventive appointment and say, 'Doctor, if we're going to cross the line from preventive to billable, I’d like you to let me know'? Would that be weird?

I don’t see anything wrong with that.

What's been your experience of the most common health care procedures or discussions that have led to what we could call 'surprise bills?'

Personally, the ones I’ve been involved with have centered around diabetes. The member goes in for a [preventative] visit and then they're also billed for an evaluation and management code for the same day with the diagnosis of diabetes, and that is a billable procedure. And there have been instances where we’ve reached out to physicians’ offices on behalf of members to confirm the procedure was distinct and separate, and in most cases, they are. It’s just about educating our members that these situations do come up, and seeing the value that it is handled all in the one visit.

So in a way it's about managing expectations of what will be free and what won't. But that sounds like a good example of how it can be hard for a patient to anticipate — you go in for a checkup, you have diabetes, your doctor asks about how your management is going, and then that turns into a charge you're liable for...Is there any helpful rule of thumb about how to know what kinds of things might turn into unexpected bills?

I really think it's about having that conversation with the physician at the time, and asking those questions during that visit.

The trouble is, things can come up while you're right in the thick of things. WBUR's Martha Bebinger has written about how free colonoscopies suddenly become billable if the doctor finds and removes polyps...

I’m so glad you brought that up. Historically, yes, and then it would process more as a surgical benefit, as opposed to processing against their routine colonoscopy. However — good news! We are now able to process claims — gastroenterologists are able to bill in such a way that even if there are polyps uncovered, that the procedure will still process against their routine benefits. Isn’t that great?

For sure — so if a patient is facing a bill for polyps during a colonoscopy, they should ask for help? Is it just Blue Cross or all insurers?

It’s been just fairly recently we’ve been able to do that — and yes, if the claim is not coded that way initially, we are able to reach out to physicians' office and help members. I can't speak for other insurers.

I confess, I'm tempted to put off my next check-up for a while. I'm sparing you the gory details of all the phone calls and the SNAFUs that led up to my debt-collection letter, but it really does hurt to spend $338 for an ear cleaning that, according to an excellent ear-wax roundup in the Wall Street Journal, I might have handled virtually for free:

...Doctors recommend softening impacted earwax with a few drops of mineral oil, baby oil, commercial ear drops or hydrogen peroxide. Then allow the loosened wax to work its way out naturally. If it still needs help, try gentle irrigation with a bulb syringe or tilt your head in the shower, say doctors. After a few minutes, straighten up and let the water run out again.

"Water works just as well as a $10 bottle of ear drops," says Dr. Rosenfeld.

Or a $446 irrigation, I suspect.

A bit of further reading on health costs: Negotiating Medical Bills (Healthcare Savvy)

Beware the Upcode — and Don't Take It Lying Down (Healthcare Savvy)