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React & Act: Medicare, money and your hospital experience


Video: Doctors were coached on diagnoses, ex-staff say

Interactive graphic: Prime reports outsized rates of unusual conditions

Former medical coding staff from Prime Healthcare Services hospitals have raised concerns about diagnoses that may misconstrue what’s going on with the patient. However, it is not always easy for patients to know what diagnoses were used as a basis for a hospital bill to Medicare.

Patients tend to get an “explanation of benefits” document from Medicare that lists the treatments, services and medications administered during a hospital stay. The document does not show which medical conditions doctors and medical coders would have assigned to an individual case.

Medicare pays hospitals based on the severity of the medical condition, which is determined by the patient’s primary diagnosis, surgical procedures and medical complications. These documents also inform Medicare whether conditions were “present on admission.” This is of interest to Medicare authorities who track whether a patient walked into a hospital with or without an infection or bedsore or other conditions that can arise during a hospital stay as a result of inadequate care.  Hospitals can lose funding in cases in which patients develop medical problems during a hospital stay.

Patients seldom get a chance to review such documents. Most hospitals submit claims electronically to Medicare. However, to request printed forms, Medicare suggests that patients call the hospital where they received care for information about what was billed. To learn more about how Medicare works, you can go to the California Health Advocates website.

Find answers to more questions below.

How do I get questions answered or lodge a complaint?

To file a complaint about a hospital, contact:

California Department of Public Health
Phone: 800-236-9747
E-mail: cdph-lnc-hfcis@cdph.ca.gov
Website: www.cdph.ca.gov/certlic/facilities/Pages/LCDistrictOffices.aspx

Phone: 800-633-4227
Write: Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore MD 21244-1850
Website: www.medicare.gov
How to file a complaint PDF: www.medicare.gov/Publications/Pubs/pdf/11313.pdf

The Joint Commission
Phone: 630-792-5800
Write: Office of Quality Monitoring
The Joint Commission
1 Renaissance Blvd.
Oakbrook Terrace, IL 60181
E-mail: complaint@jointcommission.org
Website: www.jointcommission.org
Complaint form: www.jointcommission.org/report_a_complaint.aspx

Healthcare Facilities Accreditation Program
Phone: 312-202-8258
Write: HFAP Quality/Patient Safety Services Department
c/o Susan Lautner
142 E. Ontario St.
Chicago, IL 60611
E-mail: slautner@hfap.org
Website: www.hfap.org
Interactive PDF complaint form: www.hfap.org/pdf/complaint_form.pdf

If I have concerns about a specific doctor, what do I do?

Report an error: See something wrong in this story?
E-mail our editors.

You can check with the Medical Board of California.

Medical Board of California
Phone: 800-633-2322
Write: Medical Board of California
Central Complaint Unit
2005 Evergreen St., Suite 1200
Sacramento, CA 95815
Website: www.mbc.ca.gov
Complaint information: www.mbc.ca.gov/consumer/complaint_info.html

How to contact Prime Healthcare Services:

Prime Healthcare Services
Phone: 909-235-4400
Write: 3300 E. Guasti Road
Ontario, CA 91761
E-mail: info@primehealthcareservices.com.
Website: www.primehealthcare.com

Which hospitals are owned by Prime?

Prime Healthcare Services owns 14 hospitals throughout California. Click through this map to see whether there is one in your community.

View Prime Healthcare Services Hospital Locations in a larger map

How can I tell California Watch about my experiences at a Prime hospital?

If you have been treated at a hospital owned by Prime Healthcare Services, please share your experiences with California Watch by clicking here. Your insights can inform our reporting. Also, please share this link with anyone you think might have insights. 


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