Monica Lam/California WatchJulie Schmitz (left) and her mother, Darlene Courtois, agreed to share Medicare billing information with California Watch.
The U.S. has strict laws against revealing personal medical information to the public. For reporters, that can make it difficult to put a human face on health stories.
When California Watch began probing a Prime Healthcare Services hospital in Redding – which had reported more than 1,000 Medicare patients suffering from a severe form of malnutrition – we relied on computer data kept by the state health department. The records are masked so patients cannot be identified.
But then we found that important human face.
California Watch reported this story with the cooperation of Darlene Courtois, a Medicare patient from Shingletown in rural Shasta County, and her daughter, Julie Schmitz, who monitors her mother’s care and keeps a close eye on the medical bills. Courtois became aware of our investigation and decided she wanted to tell her story.
Courtois suffers from diabetes and kidney issues, and she was hospitalized at Shasta Regional Medical Center after a fall in 2010.
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According to Medicare records, simply being admitted to Shasta Regional Medical Center gave Courtois a 19.4 percent chance of being among the patients diagnosed with kwashiorkor, a nutritional disorder more closely associated with Third World poverty.
Courtois requested a copy of her hospital records and shared them with California Watch. They showed she was treated for kidney failure, but her doctors made no mention of kwashiorkor. Nor did the records contain information about the bill the hospital submitted to Medicare to be reimbursed for her care.
And so Courtois signed a waiver authorizing California Watch to obtain her Medicare billing information from the Centers for Medicare & Medicaid Services via the Freedom of Information Act.
Hospitals use a numeric system called ICD-9 codes to submit their bills to Medicare in computer form. In Courtois’ case, the Medicare bill showed the diagnostic code for kidney failure – with a complicating diagnosis of kwashiorkor.
How did the kwashiorkor diagnosis influence the payout to the hospital?
To learn that, California Watch provided the codes from Courtois’ case to a health care data company called DRGGroupers.com. It supplies software that translates patient data into numeric values called diagnosis-related groups, or DRGs. DRGs are the system by which Medicare calculates reimbursements to hospitals and other health care providers.
The company calculated two DRG values – one for the case as actually billed and one with the kwashiorkor diagnosis deleted.
California Watch then turned to Medicare’s specialized “prospective payment system” software to learn payment information. Medicare calculates reimbursements based on DRGs and some other factors – the treating hospital, the date of hospitalization and length of stay.
The software’s readout said Prime’s Shasta County hospital was eligible for a payout of $11,463 for treating Courtois. If the kwashiorkor diagnoses were deleted, the payout would have been $4,708. That’s $6,755 less. Schmitz said she has been pleased with the quality of her mother’s medical care, but she worries about the cost to the federal government.
In reviewing her mother’s bills, “I have to scratch my head,” she said. “Silly things like $273 for a cloth sling, $22 for a four-by-four piece of gauze; it’s ridiculous the amounts of money charged.”
In that context, billing Medicare for treating her mother for kwashiorkor just wasn’t right, she said.
“Everybody’s taxes are paying for Medicare,” Schmitz said. “If people keep billing for something that is unnecessary, then we’re going to end up losing what we have. I can’t afford that; neither can my mom.”