Readers respond to the $1,206 toenail clipping

April 4, 2013

On Tuesday, I wrote about the curious case of the $1,206 toenail clipping. I also asked readers if they had similar stories. Turns out it was just the tip of the iceberg.

My story isn’t as immediately shocking as the toenail, but it’s more of a Chinese water-torture each month when I have to pay the bill.

I was diagnosed back in 2005 as needing an oxygen concentrator when I sleep – probably for the rest of my life, which I’m hoping will be another 30 years or so based on my family history.  Due to the way my insurance is set up through OPM (at first it was Blue Cross/Blue Shield, now it’s Kaiser Permanente Northwest), I do not have an option to buy the concentrator flat out – I have to rent it through a medical equipment company, and Apria is the one they go through.

For the same oxygen concentrator that I would be able to buy online for around $700 (my particular model is the Invacare Perfecto2 – available online with free shipping from Active Forever for $706.30 as of this afternoon), Apria charges $137.13 per month – I am charged a copay of 20%, or $27.42.  So far, over the past 7 years, they’ve gotten well over $10,000 out of me and my insurance companies (the price has increased some – when I first started, I was paying around $19 per month).

When I tried to talk to my insurance company about just buying the machine, I was told that it was against policy because renting it assured that someone would “monitor the equipment”.  Right.  Monitoring the equipment is apparently code for someone coming in twice a year to switch out a little 1 inch filter – at $1,645.56 per year, that’s over $800 per filter. (Yeah, I priced them too - $13.41 each.)

Another reader also got a shocking emergency-room bill -- but his insurer didn't have to pay much of it. The bigger question, he says, is why the health-care system keeps sending people to the ER in the first place:

I started to write you a lengthy story about a recent visit I made to the emergency room.  Some pretty severe stomach pain I had was elevated from a pharmacist to an urgent care to the emergency room.  At the latter, the visibly annoyed doctor gave me two juice cartons and a sandwich and sent me home after about 2 hours.  The bill we were given during check-out was something like $1600 (ludicrous!). I'm happy to report, however, that via whatever opaque machinations are behind our insurance industry, our insurance was only billed for ~$250 of it.  While that's an expensive sandwich, $250 doesn't seem so astronomical when figuring in doctor/nurse time, use of their facility, etc.

But despite our "good fortune," I write anyway to make a different point, which is that services set up to keep people out of emergency rooms probably aren't doing a very good job.  I went to the urgent care like I was supposed to (it was Sunday), and the doctor there was too scared (in my opinion) to make an actual diagnosis.  He sent me to the emergency room instead.  Not too long ago my infant daughter was in a little bit of a fall while we were on a hike.  She was fine all day, but the fall nagged my wife so much that she eventually felt like she needed to call the nurse line our insurance company runs.  All she really needed was some reassurance, but what she got was a risk-averse nurse who, no matter what my wife said, was going to recommend an emergency room visit.  My wife went with my daughter, the doctor openly cursed the existence of nurse lines, and they sent her back home.

So I'm curious if services like the urgent care and nurse lines, which are probably supposed to help keep people out of emergency rooms and keep costs down, really do the opposite.

There are also the costs that are supposed to be free:

As part of the baby delivery package for my first son, we received free “well baby checkups” for one year. (Packaging services is a good idea, right?) So I was surprised to see a $120 bill from the doctor’s office for a “developmental assessment” after each visit. My insurance company had rejected this charge, and now it was on me. With a little research, I learned that the “developmental assessment” was actually a photocopied list of questions that my wife and I answered with a pencil in the doctor’s office while we waited. The questions asked things like, “Does your baby respond to sounds?”

I was more than a little annoyed about being charged for what was, essentially, a DIY assessment of my child’s development. I did some more research, looking at both my insurance policy and the free “well baby checkups” policy. I wrote a letter to my insurance company, CC’ing the doctor’s office, and argued that this assessment was “an integral component” of the well baby checkups. I mean, what else are these visits for, other than measuring and weighing the kid and giving him a few inoculations? (I made other arguments as well, but this is the one that stuck.)

To my surprise, I got a letter a few weeks later informing me that I was no longer being billed for the charge. I don’t know the exact resolution made between my doctor’s office and insurance company – I was just happy to have won a small victory.

That reader's experience is worth thinking about: A lot of medical charges don't stand up to scrutiny and aren't in the hospital's interest to defend. But they're placed on the bill anyway on the assumption that most patients won't look, and most who do look won't contest.

And, finally, a doctor's perspective on the toenail that started all this:

I'm a practicing dermatologist who used to (if you can believe it) run a specialty clinic solely focussed on problems of the nail.

Coding for nail procedures seems like a tiny ridiculous subject, but it is actually a fascinating window into the absurdity of the coding system and of modern medicine. There is only one code for a nail biopsy - that's CPT 11755, which pays about $150 in metro Boston, about 30% more than a regular skin biopsy. That code has a description, which is "Biopsy of nail unit eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds, separate procedure." A clipping is taking a portion of the nail plate, which seems like it should apply under the above description. But this only takes 1-2 minutes and carries no risk, so it seems bizarre that it should pay that much.

Based on that common sense interpretation, the American Academy of Dermatology has warned members that code 11755 should NOT be used when this is done, as it should be considered part of the evaluation and management of the patient (for which Harvard already charged $248). Under this interpretation, the Harvard hospital is not coding correctly by using this code for a clipping.

However, a lot of dermatologists still do what Harvard does, with the reasoning that the AAD's argument is illogical until the actual description of the code is changed. Here's where it gets even weirder.

Imagine a situation where there was a growth under the nail, and the nail had to be removed to biopsy the growth. This would be a biopsy of the nailbed. The procedure might take 15-20 minutes, requires anesthesia and specialized equipment, and carries medical/legal risk (bleeding, pain, skin infection). The code for that? 11755, same as the clipping.

Now imagine a situation where there was a melanoma growing at the root of the nail. Here the dermatologist might have to flip the skin at the base of the nail, remove a portion of the nail, biopsy the growth, and suture everything back together. This would be a biopsy of the nail matrix. It could take 45-60 minutes, usually requires a nerve block, requires even more specialized equipment, and carries significant medical/legal risk (bleeding, severe pain, infection of the bone, likely permanent scarring of the nail). The code for that? 11755, same as the clipping.

It's absurd that these very different procedures would use the same exact code and be reimbursed at the same rate, despite the fact that one takes 1-2 minutes, and the other takes almost an hour. A colleague of mine brought this up to one of the committees that makes these codes and said a great solution would be to pay $5 for the clipping, pay $150 for the nailbed biopsy, and pay $500 for the matrix biopsy. That was a few years ago - no one is holding their breath for the change.

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Dylan Matthews | April 4, 2013