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By Robert Anglen for azcentral.com
Eileen Schraan’s doctor told her to call 911.
The 86-year-old woman had complained of shortness of breath and pain in her jaw, classic heart-attack symptoms. She was loaded into an ambulance and rushed to the emergency room.
Schraan was kept under observation for three days last year at Banner Baywood Medical Center in Mesa while doctors tried to determine if she’d had a heart attack. They ran labs to check for cardiac enzymes, preformed a CT scan of her chest, administered drugs for chest pain and conducted a cardiac stress test.
Results were negative. Doctors sent her home with a diagnosis of TMJ, a joint problem with her jaw. Banner coded Schraan’s bills with the same TMJ diagnosis and charged her more than $32,000.
That’s when Schraan discovered that her Medicare plan through UnitedHealthcare doesn’t cover dental issues. Because of Banner’s TMJ coding, UnitedHealthcare refused to pay her claim.
No matter Schraan was taken to the emergency room in an ambulance. No matter that doctors kept her three days while running cardiac tests. No matter that in 57 pages of emergency-room reports, TMJ was specifically listed five times amid dozens of cardiac references.
Schraan’s sons said their mother, now 87, found herself trapped between the insurance company and the hospital with no way to resolve the situation. Her situation illustrates the lack of control patients have over their hospital bills and how something as seemingly mundane as diagnosis coding can have devastating financial consequences.
As a result, simple health-care issues can turn into health-care nightmares even when the treatment is successful. This week, in a series of stories, The Republic, 12 News and azcentral.com are examining the cases of several people who highlight the larger financial problems in a fragmented health-care system.
“No way should she get a bill like this,” her son, Jay Schraan of California, said in an interview last week. “It has put so much stress on my mom.”
After battling for months with Banner Health and UnitedHealthcare to get the bill resolved, the Schraan family turned to Call 12 for Action. On Tuesday, UnitedHealthcare agreed to pay the entire $32,000 claim.
“We understand the inconvenience and frustration that Ms. Schraan and her family have experienced after her visit to Banner Baywood,” UnitedHealthcare spokeswoman Cheryl Randolph said in a statement Tuesday. “We don’t believe in putting our members in the middle of billing disputes, so we moved swiftly to overturn the denial of Ms. Schraan’s claim.”
Jay Schraan said the family was elated.
“I am so glad,” he said. “It looks like we can finally put this behind us. I am happy for my mom … It’s great, great, great.”
Eileen Schraan, who now lives in Flagstaff, does not own her home and has few assets. Her income is primarily Social Security. But she was very concerned about paying the bill, Jay Schraan said.
He said he and his brother even discussed splitting the bill and paying it for her, although the amount was also daunting for them.
“We grew up in the Midwest, where bills need to be paid,” Jay Schraan said. “It’s the principle.”
Jay Schraan said they didn’t know there was a problem until 10 months after his mother’s hospitalization, when she received the first bill. He said he thought it could be easily cleared up with a phone call. It couldn’t.
He said UnitedHealthcare officials initially blamed Banner Health, saying the hospital needed to change the coding. Banner Health officials said they could not legally change the coding; they said UnitedHealthcare should examine all of the medical records in the case and decide about paying the claim based on them.
“Billing is based solely on the diagnosis the patient receives,” Susan Karesky, Banner Health public-relations director, said in an interview last week. “We have to code based on the patient’s diagnosis. … We can’t code it as a heart attack if there wasn’t a heart attack.”
Karesky said modifying the billing codes would amount to falsifying medical records.
“The coding is correct,” Karesky said. “We believe Ms. Schraan’s issue … is with her insurer.”
Neither Banner nor UnitedHealthcare disputed the majority of Schraan’s stay at the hospital was related to a potential heart attack.
Schraan, who has a history of coronary-artery disease and high blood pressure, suffered a heart attack at age 65. At the time, Schraan told doctors she had significant jaw pain. A stent was implanted to open a blocked artery.
On Feb. 8, 2013, Schraan called her primary-care physician, complaining of similar symptoms. Her doctor advised her to call an ambulance, believing she could be having another heart attack.
Medical records show Schraan was taken to the emergency room, where she stayed until she was transferred to an observation room for two more days.
Emergency-room reports show Schraan underwent various cardiac tests. Doctors noted the need for more heart-related evaluations in written assessments and care plans. TMJ was mentioned in the reports, but only secondary to potential cardiac issues, records showed.
“She needs one more set of cardiac markers,” a doctor wrote in the report. “We will perform a stress test tomorrow morning … and I will make a decision about how to proceed. In addition, we do have a reason for her to have pain because of the CT scan does show severe right-sided (TMJ).”
Eileen Schraan was discharged Feb. 11. She was billed $32,142.
In an appeal of her case to UnitedHealthcare this month, Eileen Schraan said the first she ever heard that she had been diagnosed with TMJ was after her sons called to complain about the bill.
“I strongly disagree with the diagnosis as I have never had TMJ and therefore have never been treated for TMJ,” Eileen Shcraan wrote. “I don’t even have teeth! How did they come to the conclusion that I had TMJ? What test did they do to come to that conclusion? If they thought I had TMJ, why did they keep me for three days? If they thought I had TMJ, why did they run all the other tests to rule out a heart attack?”
Eileen Schraan argued that she should be required to pay only her $65 co-pay for an emergency-room visit. She said because she was never technically admitted into the hospital and remained in observation, she never technically left the emergency room.
“I have a history of heart disease. I had symptoms of a heart attack. I went to ER at the advice of my physician and previous history,” she wrote. “Banner clearly did test to make sure I wasn’t having a heart attack. My entire visit was considered ER and … (I) should not be responsible for any additional charges.”
Jay Schraan said when United contacted him Tuesday, a representative told him that they had upheld his mother’s appeal. He credited Call 12 for Action for the swift response.
“We were told it would be 30 days before they even looked at the appeal. We just sent it in a few days ago. They would have just gotten it,” he said. “I believe that it is (Call 12 for Action’s) phone call that got this to happen.”
His brother Joel Schraan said his family was getting nowhere by trying to resolve the bill through Banner Health or UnitedHealthcare. He said there was no agreement from insurance and hospital officials about the best way to resolve it.
He said the more his family complained, the more they learned they weren’t alone in their frustration over the health-care system.
“I have talked with more and more people who have dealt with this in the past,” Joel Schraan said. “If you are wronged, you have to fight it. You can’t give up.”
UnitedHealthcare officials promised Schraan would not be bothered again.
“As we continue to work through the claim issues with Banner Baywood, Ms. Schraan should not receive any further bills from the hospital,” Randolph said.
I am a hospital coder. Coding was not done correctly. It sounds like the documentation was available for correct coding. The hospital should have reviewed the chart, corrected the coding and resubmit the claim. Shame that the patient could not have this handled in a simple manner.
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