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  • D. Maurice Kreis

Dial C for Coding: A Chilling $30 Hitchcock Tale

In her book An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, journalist/physician Elizabeth Rosenthal devotes a whole chapter to the process known as "coding." It's all about Dr. Rosenthal's Rule No. 9 of her "Economic Rules of the Dysfunctional Medical Medical Market," that rule being: "There are no standards for billing. There's money to be made in billing for anything and everything."

Having recently read Dr. Rosenthal's book, I am the wrong person for a healthcare provider to pick a fight with over coding. Even when, as here, the provider is New Hampshire's most monolithic provider, Dartmouth Hitchcock Medical Center (DHMC), and the sum in question is a paltry $30.


It all started on July 28, when I had my annual physical with my fabulous new doctor, Benjamin Geishauser, D.O. "Dr. Ben," as he invited me to address him, only recently arrived DHMC but instantly proved himself to be knowledgeable, friendly, and helpful. He swiftly figured out why my arm was bothering me (a sore rotator cuff, for which he recommended strengthening exercises) and he helped me decide to sign up for a colonoscopy (in light of recent news of colon cancer in my family).


All's well that ended well -- even the colonoscopy a couple of months later was a blast (and I don't have colon cancer) -- until a bill arrived for $30 from DHMC. Because, here's the thing: As a state employee, I am covered by an Anthem Blue Cross/Blue Shield plan that is supposed to include an annual physical that is absolutely free. I realize that life is complicated these days, but if there is one thing of which I am certain it is that a free annual physical should not include a $30 copayment.

Most people, I realize, are too busy to fight over $30 and would just have paid the bill. Indeed, I am a busy person myself -- but I am also someone who has decided to become an activist for healthcare reform in my spare time. My chief obsession, the result of having a daughter with the expensive chronic illness known as cystic fibrosis, is the bloated cost of prescription medications. My daughter's annual bill for prescription meds is routinely north of $100,000 -- and that's in a good year!


Thus, my conscience does not allow me to shrug about a $30 payment I should not be required to make -- especially after devouring Dr. Rosenthal's book. "It is easy to feel helpless," she writes in the book's introduction. "But we, the patients, can actually do a lot to wrest control of our health from the ledgers of the medical industrial complex."

Step One was to ring up DHMC. But, it turns out, if you call DHMC to discuss a billing problem, you don't actually get to talk with anyone at Dartmouth Hitchcock Medical Center. Instead, you are shunted off to an outfit called Conifer Health Solutions -- an outside company that, according to its web site, is in the business of "providing revenue cycle and value-based care performance solutions that optimize financial performance and improve clinical outcomes." Translation: Conifer Health Solutions exists to help DHMC squeeze as much money as possible out of health insurers and, if necessary, patients like me. [Aside: The kid sticking out her tongue is my daughter, a long time ago. The woman with her arms folded is Joanne Conroy, M.D., the CEO of DHMC. Am I ridiculing Dr. Conroy? Yes I am.]


The person with whom I spoke at Conifer Health Solutions -- alas, I did not write down her name -- was friendly enough. Indeed, she offered to write off the $30 charge altogether, attributing the whole thing to muddles and disagreements over exactly what sort of health services are provided at any given outpatient visit.


Here, maybe, is where I zigged when I should have zagged. I said: Don't write off this charge -- get Anthem to pay it! My annual physical is supposed to be free! As every patient with health insurance surely knows by now, copayments are supposed to discourage people from making frivolous appointments but Anthem, to its credit, has figured out that people should be encouraged rather than discouraged from getting an annual physical. Hence, no co-pay.

This is the point at which the story gets weird and annoying. As a result of my friendly chat with Conifer Health Solutions, last week I received a letter dated October 28, 2021 (the three-month anniversary of my physical, as it happens). Here's what the letter said:


Our coding department audited the doctor's records and deemed that the charges are billed correctly, based on the services received.


The results of the review are: Coding has reviewed the documentation of the service provided. The documentation shows that you did have your annual physical on this date. During the visit the provider discussed multiple diagnoses that is [sic] not considered part of an annual physical which does result in split visit billing. The coding for this service is correct.


The letter was signed "Ariel E., Dispute Resolution Specialist, Conifer Health on behalf of Dartmouth-Hitchcock."


In other words, a few weeks ago, "Conifer Health on behalf of Dartmouth-Hitchcock" was willing to write off the $30 bucks -- presumably because such a small sum is not worth squabbling over by a big healthcare organization and its fancy consulting firm -- but now that I have had the audacity to question the coding decision some bean-counter at either DHMC or Conifer made, they are gonna go after me for that 30 bucks for sure.


Not so fast. The bill I received from DHMC sheds no light on how this whole thing was coded. Neither does the EOB ("explanation of benefits") document I received from Anthem, the salient portion of which is below:

In other words, neither DHMC nor Anthem have deigned to provide me with any information about how my annual physical was coded. So I have no way of verifying the rather ludicrous claims made by "Ariel E." of Conifer Health Systems in her letter.


But, regardless of how this thing was coded by some expert at Conifer or DHMC in an effort to "optimize financial performance," their excuse for billing me $30 is beneath contempt. I'm a middle-age man who had an annual physical so, of course, we discussed various things that might or might not be issues for me in quest of ongoing good health. We did not discuss "multiple diagnoses that [are] not considered part of an annual physical" so as to justify "split visit billing."


If this is Conifer Health Solutions' way of extracting revenge for talking back to them, well all I can say is: They picked the wrong guy to fight to the death with over $30. I will not be optimized for financial performance!

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