HEATH HORIZONS : HEALTH CARE : Remedying Medical Bills : IF YOU THOUGHT THE HOSPITAL STAY WAS TRAUMATIC, WAIT UNTIL THE BILLING DEPARTMENT GETS YOU IN THEIR CLUTCHES.

It seemed the perfect place to take a grand flop on one’s back--right there in a hospital, right in front of a nurses’ station, in fact.

I was walking down a corridor, heading for the room of my father, when I encountered an unseen puddle of who-knows-what liquid, apparently spilled moments before. My feet flew out from under me, precipitating an acrobatic half-gainer worthy of a comic circus act. Several nurses hurried to my aid and, despite my protests that I seemed OK, insisted on rushing me to the emergency room for a checkup.

“Just do one thing first,” I implored, making a request based on long experience. Before a single test was begun, I said, they needed to write two words on the medical forms: HOSPITAL PAYS.

So it was done, and I hardly gave a second thought to the quip of an emergency room supervisor, “Anything to get you in the clutches of our billing department.”

Two weeks later, it wasn’t a joke. That’s when the bills started arriving, one for $185 from the hospital and another from the radiologist who spent all of two minutes inspecting the X-rays of my back. He wanted $60.

I responded with an indignant letter recapitulating the outrageous events--and billing the hospital 29 cents for the stamp.

The result? Threats began arriving from a collection agency.

As my blood pressure zoomed into the red zone, my thoughts drifted to the film “The Hospital,” perhaps the most biting parody ever made of the American medical system. It suggested that appropriate justice for a crew of arrogant doctors was to have them become, suddenly, anonymously--and eventually fatally--patients in their own institution.

It seemed to me, at this moment, that those doctors had been let off too easy. My own lifelong string of encounters suggested a sentence worse than death. Someone should simply have sent their names to the &$%?!&% BILLING OFFICE.

I made my maiden voyage into this “Twilight Zone” two decades ago, when medical costs still seemed irrelevant to my own young life. One Monday morning, the managing editor of my newspaper back East called me aside to request “a special, highly sensitive investigation.” Naive in many ways, I assumed he was talking about an important story. “Not quite,” he said. “The publisher needs some help.”

The publisher’s son, it seems, had fallen off his bicycle, struck his head and suffered a concussion. He’d been taken to a neurologist. Now there was confusion about the bill--the insurance reimbursement, in particular.

“What am I supposed to do?” I asked. “Write something or help the boss man save money?”

The editor shrugged. “Just see what’s there,” he said. “Hey, it’s his sandbox”--this referring to the newspaper--”he can play in it any way he wants.”

The next day, I was off to see the neurologist.

He wanted help too, it turned out. He could understand the human brain, no problem, had board certification to prove it. But insurance was “a complete mystery to me,” he said. Then he tossed three years worth of files on a desk.

His confusion centered on the way Blue Shield--the major insurer for that Eastern state, covering 4 million people--paid for his most basic service, a neurological consultation. Sometimes it reimbursed the patient $32, other times $21. Same coverage, same exam, same doctor. How could that be?

Two days later, I visited the headquarters of Blue Shield to find out. The insurance company, confident there was no problem, opened its records for me, massive stacks of them. But, lo and behold, it was true: 54% of the patients got the lower payment for the neurological exam--incorrectly.

“We have got a problem,” a company official declared.

We eventually determined that it all came down to codes. Rows of clerks (“adjudicators” was their official job title) at the insurance company pored through the forms submitted by doctors, jotting in code numbers to determine the payment for each service. Often, however, they wrote in the code for a neurological exam by a non-specialist when a specialist had provided the service, meaning the lower payment. Other times, they assumed it had been a cursory checkup, not a complete neurological exam, again meaning the lesser amount.

“The key is the word complete ,” the company official said, complaining that physicians often didn’t include that magic word in describing their service.

“There are hundreds of procedures,” he said, “where the difference in one word (on the insurance form) makes a difference in the amount.”

Indeed, records for two other procedures--spinal taps and the removal of lesions on the face--similarly revealed widespread underpayments because of how clerks interpreted the doctors’ wording.

In this case, there was a happy ending. I got a story, after all. The insurance company clarified its procedures. Most importantly, the publisher got his extra $11.

But the experience provided a sobering lesson: The doctors had been well meaning. The insurance company had been well meaning. And the patients were getting screwed.

How, then, do medical practitioners learn the intricacies of Blue Cross reimbursements and the like?

The answer is, they often don’t. Medical societies sponsor regular seminars in the practical aspects of running an office, but many practitioners--understandably--prefer to contract the dirty work to an outside billing service or let the expertise accumulate in a staff member, what used to be called “one of the girls.”

The Eastern neurologist was a classic example. “I have to confess ignorance,” he said. “There are so many different (insurance) plans, I have no idea what they pay.”

“I have no idea,” he added, “what I’m covered for myself.”

My father, a retired dentist, was much the same. When he fell ill, there were three insurance plans to cover the mounting bills, a private carrier, Medicare and a catastrophic policy. Despite 50 years of practice, he couldn’t come close to understanding where one left off and another began--and he certainly didn’t need the extra frustration of trying to figure it all out.

It’s hard for any patient not to get nervous when a crisp, computerized bill arrives with a litany of charges and that subtle prod: FULL PAYMENT EXPECTED UPON RECEIPT. The patient may suspect that his insurance plans are supposed to process the claim first, but the bill says to pull out your checkbook NOW. What to do?

In my father’s case, we finally hired one of his former office assistants to come in weekly to handle the paperwork.

But in my own life, as medical bills became more than an abstract issue, I was determined to master the system myself, to try to head off problems before they escalated into major anxieties. I was determined, in other words, to practice “preventive patienting.”

I discovered in 1991, however, that this was not all that easy. Indeed, there would be two incidents to boggle the mind--and the wallet, potentially--one on each coast, one more exasperating than the next.

The bill from a Los Angeles hospital announced proudly that I was getting a “discount” of $1,038.75 from the medical equivalent of full list price. I’d merely have to pay $311.66 out of my own pocket for my knee surgery there. Great. Wonderful.

But there was one problem. I wasn’t supposed to pay anything, not a cent. We had a clear agreement--I had it on tape. How could there be a bill? The confusion had begun in the surgeon’s office, moments after he announced that I needed an operation. His billing expert came right into the examining room and explained that he was affiliated with two hospitals: the renowned Cedars-Sinai Medical Center, where there might be a two-week wait for elective surgery, or a smaller, lesser-known facility, where it could be done within days.

That would be fine, I said, as long as the smaller hospital accepted my insurance plan. Before my very eyes, she called to check, then reported that the hospital assured her it was a participating provider. So we scheduled the operation there.

Only when I arrived for “pre-op” tests and to fill out paperwork did I learn that the hospital was not, in fact, a participating provider. A pleasant billing agent seated me at her work pod, decorated with pictures of her children, and explained that what the hospital had meant was that it would be delighted to accept the insurance payment-- assuming that it covered the “customary and reasonable” costs.

It didn’t take a genius to recognize a loophole as wide as the Grand Canyon. I said “thanks but no thanks,” and announced that I would have the surgeon reschedule the procedure at Cedars.

It was then she offered the deal. A private hospital is a business like any other, free to negotiate with customers. So the billing agent said that, to keep my business, the hospital would agree to accept the insurance reimbursement as payment in full--an even better deal than at a “participating” facility, where I’d have to make a 10% co-payment.

Who could turn that down?

But a practitioner of preventive patienting takes no chances. In the 48 hours before the operation, I made three calls to confirm the arrangement. The last time, my wife got on a second line to witness the conversation and we told the hospital billing agent that we were recording the call as well. She probably notified the psychiatry department that a certified paranoid was checking in.

I did feel a bit like a foolish worrywart--until Feb. 16. That’s when the bill arrived, the one describing the hospital’s great “discount” and how I’d only have to pay $311.

My letter back was polite, matter-of-factly recounting our “series of very explicit conversations.”

“The bottom line,” I said, “is that you made an attractive offer to me to keep me from going to a more ‘glamorous’ (if such as word can be used for a hospital) competing facility.”

I went on to praise the delightful recovery room nurses, but concluded that, as for the $311: “Given our agreement, I won’t pay it.”

The call came soon after. No, I didn’t have to pay.

Again, a happy ending that left me uneasy: What would have happened to a patient who hadn’t made all those calls, who hadn’t gotten a witness?

Three months later, I flopped on my back in the hospital corridor while visiting my father, this time in New York.

The memory of the Los Angeles incident was so fresh that I passed the time, while waiting for my turn in X-ray, recounting the story to an emergency room nurse. She laughed and commented how, of course, such things never happened here. Then she filled out the paperwork noting how the hospital would pay, what with the tests being taken at their request so they could cover their you-know-what if I later claimed a skull fracture, or some such injury.

When the bills started arriving this time, my letter back was not so polite.

Addressed to “Bozos in Billing,” it began:

“Dear Mr. or Ms. Bozo. Thank you very much for the comic relief provided by your bill for $260. . . .”

I described the sequence of events, then reported that I had experienced “a distinct worsening of symptoms” since my swan dive on their premises--the relapse coming on about the time I got their bill. “These symptoms,” I related, “include aches and pains, writer’s block, sexual promiscuity, overeating, a wayward tennis backhand and, as you can understand, EXTREME mental distress. It will take years of psychiatric care, at $220 a pop out here on the coast.” I said they should consider my letter a formal claim for “appropriate processing by your legal department.” I would settle, however, for reasonable damages: the cost of the stamp--and another one if they did not call off the emergency room radiologist, who was clamoring for his extra $60. “I will anxiously await my $0.29,” the letter concluded.

There were no more bills from the hospital. But Dr. X-ray was just beginning. There were several more from him, then his collection agency. My next correspondence cannot be shared in a public forum. I did not mail it, but delivered it by hand during my next visit to New York. One copy for the hospital administrator, one to the emergency room, a third to Dr. X-ray. He was out, unfortunately, so I had to slip it under his office door. I made threats and a single demand. An apology, in writing, was to be waiting in my mail in Los Angeles when I returned.

The letter was waiting. The language was a bit formal (“We regret any misunderstanding . . .”), but an apology is an apology. So why press the issue?

I let the 29 cents slide.