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Hospital Overcharging Included $2,500 Billed for Individual Surgical Screws

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Houston, TXIt isn’t often that emergency room charges and hospital overcharging are used in the same sentence with words such as “racketeer” and “corrupt.” However, such allegations are included as part of claims brought against Houston-based North Cypress Medical Center by Aetna Life Insurance Co. At issue are allegations that due to allegedly deceptive practices, Aetna overpaid the hospital as much as $120 million.

At the center of the dispute medical bill case is Dr. Robert A. Behar, identified in court records as the CEO of North Cypress. According to court documents, physicians were offered ownership interest in North Cypress in exchange for recommendations and patient referrals to North Cypress over less-expensive, in-network facilities.

In a move that takes the issue of emergency room cost and other hospital billing disputes to a new level, North Cypress is alleged to have consistently billed Aetna for procedures that were charged at a much higher cost than similar hospitals.

As an example, it is alleged that Aetna was billed for $3.1 million for surgical anchor screws at a rate exceeding $2,500 for each screw. It is alleged that North Cypress utilized non-specific billing codes. It is also alleged that North Cypress purposely provided incorrect codes for services and procedures undertaken in various sectors of the hospital - including the emergency room - resulting in significantly higher emergency room cost.

Combined, North Cypress is alleged to have increased its gross revenues by hundreds of millions of dollars above the revenues of comparable hospitals. Doctors who consistently referred patients to North Cypress are described as having the potential to become “millionaires virtually overnight” through the acquisition of an ownership stake in the hospital as incentive. Doctors failing to refer a sufficient number of patients were reprimanded and threatened, or forced to relinquish their ownership stakes in the hospital, or so it was alleged.

Hospitals will often overcharge patients with adequate health coverage or resources to pay out-of-pocket, in order to compensate for losses incurred when treating patients who lack adequate coverage or resources. Many hospitals, however, go overboard and have been known to charge exorbitant emergency room fees and costs for other procedures. Behar and North Cypress are accused of concocting the scheme in an effort to upgrade the facility to “an upscale 5-star hotel-like ambience,” according to the complaint.

“The financial harm inflicted on Aetna and the healthcare system was not by happenstance, but by pure design,” the complaint said.
“Dr. Behar intended to harm Aetna as part of his greed and personal vendetta against the managed care industry and, in fact, routinely expressed his desire to bilk Aetna and other payors.”

The hospital overcharging lawsuit included claims under the Racketeer Influenced and Corrupt Organizations Act, in addition to claims for interference and breach of contract.

The case is Aetna Life Insurance Co. v. Robert A. Behar, M.D. et al, Case No. 4:15-cv-491 in the US District Court for the Southern District of Texas.

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READER COMMENTS

Posted by

on
The first time we heard an attorney refer to this type of situation as "racketeering", we had a "YES!" moment. Describes it perfectly. We have heard it (and other choice terms) used several times since then from other attorneys.

We are familiar with North Cypress Medical Center's charging practices and countless others like them all over the country...these rates and charging practices are all too common.

As Helen mentioned, if a patient has time to plan their procedure, they have to be proactive and find out if all specialists are in network among other things. But even with proper preparation there can be all kinds of surprises and extremely unreasonable charges.

Daphney Elliott
w- http//:www.HospitalBillReview.com

Posted by

on
Dear Mr. Gibb, Esq.,
Thank you for posting this poignant article. As a medical auditor of medical insurance claims, fees, etc., I too can attest to these type of overages. What is outrageous is the math when you add up the fact these plates that the screws are used on can easily have 4-8, or more holes in each plate. The (4) holed plate would then bill for, $10,000.00 for just the screws used to anchor this plate. The (8) holed plate, twice that amount or, $20,000.00. Given the fact these plates are supposed to be made out of titanium only, I shudder to think how much the fee for each one of them would be charged? Typically, (2) might be used depending on the severity of the fracture to a tibia or fibula fracture as an example. There are even larger plates with more openings for the screws in them.
The bottom line being, any provider that has a vested interest in one of these surgical centers is obligated to post a sign in their office. The sign MUST be in a conspicuous place to all to see/read! The person who needs surgery should also ask if the other Doctors participate with their insurance? (Anesthesia, Assistant Surgeon, RN-First Assistant, Physician Assistant, etc.). The patient may very well need to find out this information themselves.
Thank you again.
Helen Strasko, RN, CPC, CLNC, CCRN-R
Certif. Professional Coder
Certif. Legal Nurse Consultant
Certif. Critical Care RN
W- http//:www.AtlanticLegalNurseConsultants.com

Posted by

on
This hospital did the same to me....I got a tetnus shot...the wound was no larger than 1/8 inch on my hand. The doctor asked me if I wanted imaging, I said no. They want me to pay over $2,000 for a shot I could have received a Walgreen for $67. I did not claim insurance - so they said they reduced my bill. This is criminal...

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