醫(yī)療賬單上，隱藏的收費防不勝防

After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know

醫(yī)療賬單上，隱藏的收費防不勝防

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

12月，37歲的彼得·德里耶(Peter Drier)因椎間盤突出接受了三個小時的頸部手術(shù)。術(shù)前，他簽署了一大堆同意書。身為銀行的技術(shù)經(jīng)理，德里耶充分研究過自己醫(yī)保的賠付范圍，所以當(dāng)賬單陸續(xù)發(fā)到時，他早已做好了心理準(zhǔn)備——曼哈頓勒諾克斯山醫(yī)院(Lenox Hill Hospital)的5.6萬美元，麻醉師的4300美元，甚至還有骨科醫(yī)生的13.3萬美元，他知道后者只能接受那筆費用的一小部分。

He was blindsided, though, by a bill of about $117,000 from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.

然而，當(dāng)他看到一名“外科助理醫(yī)生”發(fā)來的約11.7萬美元的賬單，他還是傻了眼，記憶中他根本不曾見過這名皇后區(qū)的神經(jīng)外科醫(yī)生。

“I thought I understood the risks,” Mr. Drier, who lives in New York City, said later. “But this was just so wrong — I had no choice and no negotiating power.”

“我以為自己已經(jīng)充分了解了其中的風(fēng)險，”家住紐約市的德里耶后來這么說道。“但是我錯了，錯得離譜——我根本沒有選擇的余地，也沒有討價還價的權(quán)力。”

In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.

在全美各地，醫(yī)生和其他醫(yī)療服務(wù)提供者常常在手術(shù)室和醫(yī)院病房中互相幫助，協(xié)力完成患者的醫(yī)護(hù)工作。但是，一種被部分醫(yī)療專家稱為“隱蔽性強(qiáng)迫醫(yī)療”的做法正日益普遍——無論助理醫(yī)生還是醫(yī)療顧問，甚至連醫(yī)院的其他員工都開始向患者或其保險公司收取高昂的費用，盡管有時他們的加入并沒有什么必要。而患者往往是直到結(jié)算賬單之時，才發(fā)現(xiàn)有一大堆人參與了自己的醫(yī)護(hù)過程，并為此計費。

The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant because, as in Mr. Drier’s case, they may involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount, or a substantial portion.

當(dāng)保險公司不斷削減眾多醫(yī)療服務(wù)的報銷額度時，這種做法顯然可以增加醫(yī)生和其他醫(yī)護(hù)人員的收入。從德里耶的案例可以看出，此類意外費用可能極高，因為其中可能涉及醫(yī)保網(wǎng)絡(luò)外的醫(yī)療保健提供者，而他們的收費往往高達(dá)平常的地方醫(yī)療費率的20到40倍，而且報銷額度極低，甚至完全不能報銷。

“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. This contributes to the nation’s $2.8 trillion in annual health costs.

“這樣，通過增加可收費項目，你就繞過了價格管制。”不久前剛離職的前布魯金斯學(xué)會(Brookings Institution)衛(wèi)生政策專家達(dá)沙克·桑加維(Darshak Sanghavi)說。全美的年醫(yī)療費用達(dá)到2.8萬億美元，其中不乏此類原因的推動。

Insurers, saying the surprise charges have proliferated, have filed lawsuits challenging them. In recent years, unexpected out-of-network charges have become the top complaint to the New York State agency that regulates insurance companies. Multiple state health insurance commissioners have tried to limit patients’ liability, but lobbying by the health care industry sometimes stymies their efforts.

保險公司表示他們已經(jīng)對這些激增的意外收費提起訴訟。近年來，在紐約州保險公司監(jiān)管機(jī)構(gòu)收到的投訴中，意外的網(wǎng)絡(luò)外收費居于首位。也有多位州醫(yī)療保險監(jiān)察官試圖減輕患者負(fù)擔(dān)，但保健行業(yè)的游說不時阻撓他們的工作。

“This has gotten really bad, and it’s wrong,” said James J. Donelon, the Republican insurance commissioner of Louisiana. “But when you try to address it as a policy maker, you run into a hornet’s nest of financial interests.”

“事態(tài)已經(jīng)演變到了相當(dāng)糟糕的程度，這樣是不對的，”路易斯安那州共和黨的保險監(jiān)察官詹姆斯·J·唐龍(James J. Donelon)說。“但是，每當(dāng)政策制定者試圖解決這個問題，總會捅到經(jīng)濟(jì)利益的馬蜂窩。”

In Mr. Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had said he would accept a negotiated fee determined through Mr. Drier’s insurance company, which ended up being about $6,200. (Mr. Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T. Mu, was out of network and sent the $117,000 bill. Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Dr. Tindel’s office says he and Dr. Mu do not. Dr. Mu’s office did not respond to requests for comment.

以德里耶為例，他的主刀醫(yī)生納撒尼爾·L·廷德爾(Nathaniel L. Tindel)表示愿意接受德里耶的保險公司提出的議價，即約6200美元。(其中德里耶須支付3000美元，才能達(dá)到免賠額。)但助理醫(yī)生哈里森·T· 穆(Harrison T. Mu)不在醫(yī)保網(wǎng)絡(luò)之內(nèi)，而他發(fā)出的賬單竟達(dá)11.7萬美元。保險專家稱，醫(yī)生和助理醫(yī)生有時會分享手術(shù)的收益，但廷德爾醫(yī)生的辦公室表示他們與穆之間無此協(xié)議。穆的辦公室沒有回應(yīng)記者的采訪請求。

The phenomenon can take many forms. In some instances, a patient may be lying on a gurney in the emergency room or in a hospital bed, unaware that all of the people in white coats or scrubs who turn up at the bedside will charge for their services. At times, a fully trained physician is called in when a resident or a nurse, who would not charge, would have sufficed. Services that were once included in the daily hospital rate are now often provided by contractors, and even many emergency rooms are staffed by out-of-network physicians who bill separately.

在醫(yī)院里，這種“隱蔽性強(qiáng)迫醫(yī)療”可能以多種不同的形式出現(xiàn)。在某些情況下，可能患者躺在急診室的輪床上或醫(yī)院的病床上，渾然不知從他床邊晃過的所有穿白大褂或手術(shù)衣的人都是要收費的。有時，明明不需額外收費的住院醫(yī)生或護(hù)士就足以應(yīng)付局面，偏偏要呼叫訓(xùn)練有素的?？漆t(yī)師前來。許多原本應(yīng)在醫(yī)院日常收費范圍內(nèi)的服務(wù)現(xiàn)在改由承包商提供，甚至許多急診室都在使用單獨收費的網(wǎng)絡(luò)外醫(yī)生。

Patricia Kaufman’s bills after a recent back operation at a Long Island hospital were rife with such charges, said her husband, Alan, who spent days sorting them out. Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition.

帕特里夏·考夫曼(Patricia Kaufman)前不久在長島醫(yī)院(Long Island hospital)接受了背部手術(shù)，此后她的賬單中就充斥著此類費用，她的丈夫艾倫(Alan)花了數(shù)天時間才將它們揀選整理出來。兩名整形外科醫(yī)生要求的切口縫合費超過了25萬美元，而在考夫曼女士此前經(jīng)歷的手術(shù)中(她患有慢性神經(jīng)系統(tǒng)疾病，需要多次手術(shù))，這一工作一向是由住院醫(yī)生完成的。

In the days after the operation, “a parade of doctors came by saying, ‘How are you,’ and they could be out of network or in network,” Mr. Kaufman said. “And then you get their bills. Who called them? Who are they?”

手術(shù)后的那幾天，“成群結(jié)隊的醫(yī)生——也不知道是網(wǎng)絡(luò)內(nèi)的還是網(wǎng)絡(luò)外的——從你身邊走來過去，順口問候你一句，然后你就會收到他們的賬單，”考夫曼先生說。“誰把他們叫來的?他們究竟是些什么人?”

Doctors’ offices often pursue patients for payment. Ms. Kaufman’s insurer paid about $10,000 to the plastic surgeons, who then sent a bill for the remainder. The couple, of Highland Park, N.J., refused to pay.

醫(yī)生辦公室一般都會向患者追討費用?？挤蚵康谋ｋU公司已經(jīng)向整形外科醫(yī)生支付了約1萬美元，結(jié)果他們又發(fā)了一份賬單列舉了其余的費用。這一次，這對生活在新澤西州海蘭帕克市的夫婦表示拒絕支付。

When insurers intervene in a particular case, they say they have limited ability to fight back. Insurance examiners “are not in the room on the day of surgery to see the second surgeon walk into the room or why they were needed,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry group. And current laws do not require hospitals that join an insurance network to provide in-network doctors, labs or X-rays, for example.

當(dāng)保險公司介入特定的案例時，他們往往表示自己有心無力。美國保險業(yè)的行業(yè)組織——美國醫(yī)療保險計劃(America’s Health Insurance Plans)的女發(fā)言人克萊爾·克魯辛(Clare Krusing)稱，保險核查員“在手術(shù)當(dāng)天并不在場，無法確認(rèn)是否有第二名外科醫(yī)生進(jìn)入手術(shù)室以及為何需要額外的醫(yī)生。”而現(xiàn)行法律也并未要求參加保險網(wǎng)絡(luò)的醫(yī)院必須提供網(wǎng)絡(luò)內(nèi)的醫(yī)生、實驗室化驗或X射線檢查等。

So sometimes insurers just pay — to protect their customers, they say — which encourages the practice. When Mr. Drier complained to his insurer, Anthem Blue Cross Blue Shield, that he should not have to pay the out-of-network assistant surgeon, Anthem agreed it was not his responsibility. Instead, the company cut a check to Dr. Mu for $116,862, the full amount.

所以有時候保險公司只好照價付款，以保護(hù)他們的客戶(起碼他們自己是這么說的)，但這無疑又鼓勵了這種漫天要價的“隱蔽性強(qiáng)迫醫(yī)療”。當(dāng)?shù)吕镆蚱浔ｋU公司安盛藍(lán)十字藍(lán)盾公司(Anthem Blue Cross Blue Shield)投訴，表示自己不應(yīng)為網(wǎng)絡(luò)外的助理外科醫(yī)生付費時，安盛也認(rèn)同那確實不是他的責(zé)任。于是公司向穆醫(yī)生開具了一張面額為116862美元的支票，全額支付。

Unexpected Fees

意想不到的費用

When Mr. Drier agreed to surgery in December, he was not in a good position to bargain or shop around. Several weeks earlier, he had woken up to excruciating pain in his upper back and numbness and weakness in two fingers of his left hand, which persisted. A scan showed that one of the disks that normally serve as cushions between vertebrae was herniated and pushing on a nerve. With a busy job and social life, he was living on painkillers.

12月，當(dāng)?shù)吕镆馐中g(shù)時，形勢可容不得他去討價還價或者貨比三家。早在幾周之前，他的背部就已經(jīng)出現(xiàn)難以忍受的疼痛和麻木，左手還有兩個手指持續(xù)乏力。掃描顯示，那些本應(yīng)在脊椎之間起緩沖作用的椎間盤之中，有一個椎間盤突出了，并壓迫了神經(jīng)。但由于工作和社交生活過于繁忙，他只能靠止痛藥撐著。

The rate of spinal surgery in the United States is about twice that in Europe and Canada, and five times that in Britain, said Dr. Richard A. Deyo of Oregon Health and Science University, who studies international comparisons. Studies are limited but have generally concluded that after two years, patients who have surgery for disk problems do no better than those treated with painkillers and physical therapy — although the pain, which can be debilitating, resolves far more rapidly with surgery.

俄勒岡健康與科學(xué)大學(xué)(Oregon Health and Science University)的理查德·A·戴約(Richard A. Deyo)在對世界各國的情況進(jìn)行比較研究后表示，美國的脊柱手術(shù)率約為歐洲或加拿大的兩倍，約為英國的五倍。盡管相關(guān)的研究有限，但一個普遍的結(jié)論是：雖然采用手術(shù)方式治療椎間盤問題能使患者更快地擺脫疼痛的侵?jǐn)_(疼痛可能致使人身體虛弱)，但手術(shù)患者在兩年后的情況并不比接受止痛劑和物理療法的患者更好。

The United States has more neurosurgeons per capita than almost any other developed country, and they compete with orthopedists for spinal surgery. At the same time, Medicare and private insurers have reduced payments to surgeons. The average base salary for neurosurgeons decreased to $590,000 in 2014 from $630,000 in 2010, according to Merritt Hawkins, a physician staffing firm.

以人均神經(jīng)外科醫(yī)生的數(shù)量而言，美國在所有發(fā)達(dá)國家中位居前列。在脊柱外科中，這些神經(jīng)外科醫(yī)生與骨科醫(yī)生形成了競爭關(guān)系。與此同時，聯(lián)邦醫(yī)療保險 (Medicare)和私營保險公司支付給醫(yī)生的費用卻在減少。根據(jù)醫(yī)生人力資源公司梅里特·霍金斯(Merritt Hawkins)的報告，2014年，神經(jīng)外科醫(yī)生的平均基本工資已經(jīng)從2010年的63萬美元降至59萬美元。

To counter that trend, some spinal surgeons have turned to consultants — including a Long Island company called Business Dynamics RCM and a subsidiary, the Business of Spine — that offer advice on how to increase revenue through “innovative” coding, claim generation and collection services.

針對這一趨勢，一些脊柱外科醫(yī)生轉(zhuǎn)職顧問行業(yè)(其中包括長島的一家名為Business Dynamics RCM的公司及其子公司Business of Spine)，告訴顧客如何“創(chuàng)造性地”通過難懂的行話、無中生有的費用申報和收賬服務(wù)來增加收入。

Some strategies used by surgeons, including billing large amounts for a second surgeon in the room or declaring an operation an emergency, raise serious questions. The indications for immediate spinal surgery, such as loss of bladder function or rapidly progressive paralysis, are rare. But insurers are more likely to reimburse a hospital or surgeon with whom they do not have a contract if a case is labeled an emergency.

一些外科醫(yī)生采用的策略，包括為手術(shù)室再加一名外科醫(yī)生而收取巨額費用，或聲稱某一手術(shù)為緊急手術(shù)等，引起了嚴(yán)重的問題。緊急脊柱外科手術(shù)的適應(yīng)證，如喪失膀胱功能或快速進(jìn)行性麻痹等均非常罕見。不過，倘若某一病例被標(biāo)記為緊急病例，保險公司向未簽合同的醫(yī)院或醫(yī)生報銷醫(yī)療費用的機(jī)會更大。

Mark Sullivan, 46, of New Jersey, went to an emergency room last year with excruciating lower back pain and leg weakness. He was in the operating room less than 24 hours later. “The surgeon stood at the foot of my bed and said, ‘You need surgery; you won’t walk out of the hospital,’ ” he recalled.

去年，46歲的新澤西州人馬克·沙利文(Mark Sullivan)因劇烈腰痛和下肢無力到急診室就診。不到24小時，他就被送進(jìn)了手術(shù)室。“當(dāng)時，”沙利文先生回憶道，“外科醫(yī)生站在床腳對我說：‘你需要動手術(shù)，不然你可能就走不出醫(yī)院的大門了。’”

Mr. Sullivan’s emergency admission made it easier for an out-of-network surgeon to perform the operation and bill $29,000. The insurer paid $9,500, and Mr. Sullivan paid about $580, as required by his plan. When the doctor’s billing office pursued Mr. Sullivan for the balance of the bill and even threatened to turn his account over to collection, he agreed to file an appeal with his insurer for additional payment, but he refused to pay more himself.

沙利文的急診入院大大便利了網(wǎng)絡(luò)外的醫(yī)生參與他的手術(shù)，并為此收費2.9萬美元。保險公司支付了其中的9500美元，沙利文也按照其保單的要求支付了約580美元。該醫(yī)生的醫(yī)保結(jié)算辦公室向沙利文追討手術(shù)費余額，甚至威脅采取強(qiáng)制追討途徑，沙利文同意向保險公司申訴要求支付其余的費用，但他自己拒絕再出一分錢。

A Last-Minute Surprise

最后一分鐘的“驚喜”

Mr. Drier’s concern about extra charges began even during his preoperative physical. The hospital sent his blood tests to an out-of-network lab and required him to have an echocardiogram (eventually billed for $950), even though he had no cardiac history. (The American Society of Echocardiography discourages such testing for patients with no known heart problems.)

早在德里耶接受術(shù)前檢查時，他就已經(jīng)開始對額外收費問題顧慮重重。醫(yī)院將他的血液化驗發(fā)送給了一家網(wǎng)絡(luò)外的實驗室，還在他并無心臟病史的情況下要求他接受超聲心動圖檢查(最后收費950美元)。(美國超聲心動圖學(xué)會[American Society of Echocardiography]不鼓勵對無已知心臟問題的患者進(jìn)行此類檢查。)

His worries escalated as he lay prepped for the operating room on the morning of his surgery. A technician from a company called Intraoperative Monitoring Service L.L.C. asked him to sign a financial consent form, noting that the company did not accept Blue Cross Blue Shield plans, so he would be required to pay the bill himself. The monitoring had been ordered by his surgeon and is considered essential for the type of neurosurgery he was having, to make sure delicate nerves are not damaged as they are manipulated.

手術(shù)當(dāng)天的上午，當(dāng)他躺在手術(shù)室里，準(zhǔn)備接受手術(shù)時，他的憂慮進(jìn)一步加劇了。一名自稱來自手術(shù)監(jiān)測服務(wù)有限公司(Intraoperative Monitoring Service L.L.C.)的技術(shù)人員要求他簽署一份財務(wù)同意書，聲明由于該公司不接受藍(lán)十字藍(lán)盾公司的醫(yī)保方案，德里耶將需要自己支付賬單。他的外科醫(yī)生為他訂購了該公司的監(jiān)護(hù)服務(wù)，稱該監(jiān)護(hù)可確保精細(xì)的神經(jīng)不會在手術(shù)操作中受到損害，因此對于他要接受的這類神經(jīng)外科手術(shù)必不可少。

“I demanded to know the price, and when he said he didn’t know, I made him call,” Mr. Drier recalled. When the technician said it would be $500 plus an hourly rate, Mr. Drier negotiated it down to $300.

“我要求先知道價錢，他說他也不知道，于是我就讓他打電話去問，”德里耶回憶說。然后技術(shù)人員告訴他：“起步價”為500美元，其余部分按小時計費，經(jīng)過一番協(xié)商，雙方同意將基礎(chǔ)費用砍到300美元。

In the operating room, he underwent a procedure called spinal fusion, in which the surgeons removed two herniated disks that were impinging on nerves, and inserted some bone graft as well as plates and screws to stabilize the spine. On his hospital bill, Mr. Drier noted charges for three implants, a total of about $10,400, as well as for two surgical screws billed at $2,470 and $3,990 — expensive for hardware, he thought, but his insurer paid the full amount.

在手術(shù)室中，德里耶接受了脊柱融合術(shù)。外科醫(yī)生切除了壓迫神經(jīng)的兩個突出的椎間盤，然后插入骨移植物、鋼板和螺釘來固定脊柱。在醫(yī)院發(fā)來的賬單中，德里耶發(fā)現(xiàn)三個植入物收費約10400美元，兩枚手術(shù)螺釘則分別要價2470美元和3990美元——這可真是天價螺釘，他想，但他的保險公司支付了全部費用。

The biggest surprise was the bill from Dr. Mu, the assistant surgeon. Fusions generally require a second trained pair of hands, but those can be provided by a resident or a neurosurgical nurse or physician assistant employed by the hospital, for whom there is no additional charge. The operative record for Mr. Drier’s surgery states that no qualified resident was available.

而最大的“驚喜”莫過于助理外科醫(yī)生穆發(fā)來的賬單。通常，融合術(shù)確實需要有一個受過專業(yè)訓(xùn)練的人來配合主刀醫(yī)生，但這一任務(wù)完全可以由住院醫(yī)生、神經(jīng)外科護(hù)士或助理醫(yī)生承擔(dān)，他們都是無需額外收費的。在德里耶的手術(shù)記錄上是這樣寫的：沒有符合資格的住院醫(yī)生可用。

Dr. Mu is the chief of neurosurgery at Jamaica Hospital Medical Center in Queens, though he sometimes operates at other hospitals. According to a database that tracks hospital admissions in New York State, most operations he performs at Jamaica involve emergency surgery on Medicaid patients, often victims of trauma — a challenging but probably not very lucrative practice.

穆是皇后區(qū)牙買加醫(yī)院醫(yī)學(xué)中心(Jamaica Hospital Medical Center)的神經(jīng)外科主任，但他時不時也會到其他醫(yī)院做手術(shù)。據(jù)跟蹤紐約州醫(yī)院接診情況的數(shù)據(jù)庫顯示，他在牙買加醫(yī)院進(jìn)行的大部分手術(shù)都是聯(lián)邦醫(yī)療補助( Medicaid)計劃覆蓋的緊急手術(shù)。這些患者往往是外傷受害者，這一類手術(shù)的風(fēng)險和難度都很大，收入?yún)s不高，做起來委實不夠合算。

One insurer, Aetna, is in court with Dr. Mu’s private-practice group, NeuroAxis Neurosurgical Associates of Kew Gardens, Queens. NeuroAxis sued to recover higher payments for its out-of-network assistant surgeons; Aetna says the practice’s fees for those surgeons are excessive. J. Edward Neugebauer, chief litigation officer at Aetna, said the company had also sued an in-network neurosurgeon on Long Island who always called in an out-of-network partner to assist, resulting in huge charges. The surgeons shared a business address.

目前，安泰保險公司(Aetna)正與穆的私人診所組織——皇后區(qū)邱園神經(jīng)軸神經(jīng)外科協(xié)會(NeuroAxis Neurosurgical Associates of Kew Gardens, Queens)對簿公堂。“神經(jīng)軸”提起訴訟，要求追討其網(wǎng)絡(luò)外助理醫(yī)生的高額費用，而安泰則認(rèn)為，這些診所為上述醫(yī)生收費過高。安泰的首席訴訟官J·愛德華·諾伊格鮑爾(J. Edward Neugebauer)表示，該公司還起訴了長島的一名網(wǎng)絡(luò)內(nèi)神經(jīng)外科醫(yī)生，因為他總是要求網(wǎng)絡(luò)外的合作伙伴協(xié)助，造成巨額的醫(yī)療費用。這些外科醫(yī)生甚至還共用同一個辦公地址。

Surgeons from other specialties also team up: After Gunther Steinberg of Portola Valley, Calif., had a needle biopsy of an eye lesion in 2010, he discovered that his insurer had paid about $10,000 to the eye surgeon who performed the outpatient procedure and $10,700 to a second ophthalmologist in the room.

在其他醫(yī)學(xué)?？频耐饪漆t(yī)生中，也存在類似的組隊現(xiàn)象。2010年，家住加州波托拉谷的岡瑟·斯坦伯格(Gunther Steinberg)接受了眼部病灶的穿刺活檢，其后，他發(fā)現(xiàn)自己的保險公司除了向門診的眼科醫(yī)生支付了約1萬美元之外，還向手術(shù)室里的另一名眼科醫(yī)生支付了10700美元。

“The idea of having an assistant in the O.R. has become an opportunity to make up for surgical fees that have been slashed,” said Dr. Abeel A. Mangi, a professor of cardiac surgery at Yale, who said the practice had become commonplace. “There’s now a whole cadre of people out there who do not have meaningful appointments as attending surgeons, so they do assistant work.”

“在手術(shù)室里使用助理醫(yī)生已經(jīng)成為撈回被削減的手術(shù)費的一個大好機(jī)會，”耶魯大學(xué)的教授阿比爾·A·曼吉(Abeel A. Mangi)博士說，這種做法已經(jīng)司空見慣。“現(xiàn)在有一大堆醫(yī)生沒有出診外科醫(yī)生這樣的正經(jīng)頭銜，于是他們就做助理工作。”

In Mr. Drier’s case, each surgeon billed for each step of the procedure. Dr. Tindel billed $74,000 for removing two disks and an additional $50,000 for placing the hardware that stabilized Mr. Drier’s spine. Dr. Mu billed $67,000 and $50,000 for those tasks.

在德里耶的案例中，每位醫(yī)生都針對手術(shù)中的各個步驟事無巨細(xì)地收取了費用。廷德爾醫(yī)生切除了兩個椎間盤，收費7.4萬美元;安置螺釘之類的部件固定德里耶的脊柱，又是5萬美元。穆則為上述程序分別要價6.7萬美元和5萬美元。

If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon’s fee. With current Medicare rates, that would have been about $800, less than 1 percent of what Dr. Mu was paid.

假若手術(shù)的對象是一名聯(lián)邦醫(yī)?；颊?，那助理醫(yī)生的收費將不得超過主刀醫(yī)生的16%。按照目前聯(lián)邦醫(yī)保的保險費率，不過800美元上下，還不到穆的收費的1%。

Visitors Who Bill

開賬單的外來者

Unexpected fees are routinely generated outside the operating room as well. On the wards, a dermatologist may be called in to examine a rash and perform an expensive biopsy. The person in scrubs who walks a patient to a bathroom for the first time after hip surgery may turn out to be a physical therapist billing $400.

意外費用也常常產(chǎn)生在手術(shù)室之外。在病房，一個皮疹可能就會招來皮膚科醫(yī)生，又檢查又進(jìn)行昂貴的活檢。髖關(guān)節(jié)手術(shù)后，那個身穿手術(shù)服、護(hù)送患者初次去洗手間的家伙搞不好其實是個物理治療師，給你留下400美元賬單。

Mr. Sullivan, who had the emergency back surgery, discovered charges from more than 10 providers in the 48 hours after his operation. (The surgery involved simply trimming a herniated disk in his lower back.) He wrote to various doctors to dispute bills, saying, “I was admitted to Overlook Hospital from Nov. 26-27, 2013, and I have received numerous invoices for procedures that were never done, by physicians that never treated me.”

沙利文先生發(fā)現(xiàn)，在他接受緊急背部手術(shù)后的48小時內(nèi)，就有10多個醫(yī)療保健提供者要求收取各種費用。(該手術(shù)僅涉及對其腰部的椎間盤突出進(jìn)行細(xì)微的修整。)他給許多不同的醫(yī)生們寫信，對這些賬單提出了異議：“2013年11月26日至27日期間我在遠(yuǎn)景醫(yī)院(Overlook Hospital)就診，但是，一大堆從來沒有治療過我的醫(yī)生卻以各種我從未接受過的醫(yī)護(hù)程序為名，給我開了無數(shù)賬單。”

He was puzzled by $679 in occupational therapy charges involving the delivery of a device to help him put on his socks, which he never used. He was irate about charges from a group of hospital-based primary care physicians from Inpatient Medical Associates, who visited him briefly once a day and billed close to $1,000 in out-of-network costs.

其中一項金額為679美元的職業(yè)療法(occupational therapy)賬單顯示，他使用了一種可以協(xié)助自己穿襪子的設(shè)備，這讓他迷惑不解，因為他從未用過這玩意兒。等他看到一幫住院醫(yī)療協(xié)會 (Inpatient Medical Associates)的駐院初級保健醫(yī)生發(fā)來的賬單時，他已經(jīng)極度憤怒了——那些人每天只在他面前轉(zhuǎn)一圈，卻要按照網(wǎng)絡(luò)外醫(yī)生的收費標(biāo)準(zhǔn)收取近1000 美元的費用。

Healthy surgical patients typically do not need a general doctor; an anesthesiologist clears them for surgery. Mr. Sullivan noted that if he had needed an internist, he would have called his own, who is in his insurance network and whose office is just down the block.

健康的手術(shù)患者通常并不需要全科醫(yī)生;麻醉師可以確定他們能否接受手術(shù)。沙利文先生也表示，如果他需要內(nèi)科醫(yī)生，他會打電話給自己的醫(yī)生的，那位醫(yī)生不但在保險網(wǎng)絡(luò)之內(nèi)，而且其辦公室就在這個街區(qū)不遠(yuǎn)處。

Dr. Mangi, the Yale cardiac surgeon, said hospitals often encouraged extra visits for both billing and legal reasons. He said he was required to request a physical therapy consult before each discharge, for example, even if he felt there was no need.

耶魯大學(xué)的心臟外科醫(yī)生曼吉博士表示，出于收費以及法律方面的原因，醫(yī)院往往會鼓勵外來的醫(yī)護(hù)人員參與醫(yī)護(hù)過程。例如，每次有患者要出院時，醫(yī)院總是要求他提請為患者進(jìn)行物理治療會診，即使有時候他覺得完全沒那個必要。

“You can cut fees, but institutions find ways” to make the money back, he said. “There’s been a mushrooming industry of mandatory consultants for services that neither doctors nor patients want.”

“你可以削減費用，但醫(yī)療機(jī)構(gòu)總會想方設(shè)法”把錢賺回來，他說。“強(qiáng)制性服務(wù)咨詢行業(yè)像雨后的蘑菇一樣冒了出來，但無論是醫(yī)生也好，患者也好，其實都不想要這些東西。”

A Possible Remedy

一種可能的解決之道

For months, Mr. Drier stewed over what to do with the $117,000 check Anthem Blue Cross had sent him to pass on to Dr. Mu, refusing to sign over a payment he considered “outrageous and immoral.” He worried that such payments could drive up premiums at his employer.

幾個月來，德里耶輾轉(zhuǎn)反側(cè)，不知該拿安盛藍(lán)十字要他轉(zhuǎn)交給穆的那11.7萬美元支票怎么辦。他不愿意簽付這筆在他看來“高得離譜，簡直不道德”的款項。他擔(dān)心這樣的費用可能會抬高其雇主的保險費。

In the past few years, some insurers have filed lawsuits and sought injunctions to prevent providers from going after their clients for payment of unexpected medical bills. Dr. Scott Breidbart, chief medical officer at Empire Blue Cross Blue Shield, part of the same parent company that covers Mr. Drier, said that it had not taken that route, but that in some situations it had refused to do further business with in-network surgeons who repeatedly called in out-of-network assistants.

在過去的幾年中，一些保險公司已經(jīng)提起訴訟，要求頒布禁令，防止醫(yī)療保健提供者向他們的客戶追討意外的醫(yī)療帳單。帝國藍(lán)十字藍(lán)盾公司(Empire Blue Cross Blue Shield，從屬于為德里耶承保的母公司)的首席醫(yī)療官斯科特·布雷德巴特(Scott Breidbart)博士稱，目前他們尚未采取這條途徑，但在某些情況下，該公司將拒絕與一再要求網(wǎng)絡(luò)外助理醫(yī)生參與醫(yī)護(hù)服務(wù)的網(wǎng)絡(luò)內(nèi)外科醫(yī)生繼續(xù)合作。

A New York State law that will take effect in March — one of a few nationally — will offer some protection against many surprise charges and require more advance disclosure from doctors and hospitals on whether their services are covered by insurance. It states, for example, that patients are not responsible for unforeseen out-of-network charges beyond what they would have paid in-network. It directs insurers and hospitals to negotiate any further payment or enter mediation.

紐約州的相關(guān)法律將在3月生效。在全美范圍內(nèi)，此類法律尚屬少數(shù)，它將為患者及其保險公司提供一定程度的保護(hù)，幫助他們應(yīng)對多種意外收費，并將要求醫(yī)生和醫(yī)院提前披露他們的服務(wù)是否在投保范圍。例如，它指出，患者將無需為超出網(wǎng)絡(luò)內(nèi)醫(yī)療費用限度的不可預(yù)見的網(wǎng)絡(luò)外收費負(fù)責(zé)。它還將指導(dǎo)保險公司和醫(yī)院如何就額外的費用進(jìn)行協(xié)商或進(jìn)入調(diào)解程序。

In many other countries, such as Australia — where, as in the United States, people often rely on private insurance — it is seen as a patient’s right to be informed of out-of-pocket costs before hospitalization, said Mark Hall, a law professor at Wake Forest University.

維克森林大學(xué)(Wake Forest University)的法學(xué)教授馬克·霍爾(Mark Hall)認(rèn)為，在美國、澳大利亞以及其他許多國家中，人們往往依賴于私人保險，因此在住院前了解自己的實付費用是患者的正當(dāng)權(quán)益。