GUEST COLUMN – Beyond explanation


I’m a new member of Medicare, and not long ago I had my Welcome to Medicare Physical Evaluation. A PSA test was part of the exam. As I’ve done for years, I had the blood taken at the Windham Nordx offices. About two months later, Nordx billed me for the test.

I included a note on their bill saying Medicare covers this test (I checked in their booklet) and sent it on its way. A month later Nordx billed me again.

This time I put a copy of the Medicare page that confirms the PSA coverage and another note, this one in more urgent language explaining that Nordx had no chance of receiving any money from me. Ever. End of discussion. A month later I got another bill.

I like the convenience of the local Nordx office. You don’t even need an appointment. They have Down East magazine in the lobby. I need Nordx, so I called Medicare to ask why they had denied the lab’s bill. Eventually a friendly Medicare man located my records on-screen and said to me, “Because the outcome didn’t match the diagnosis.”

I paused to make sure I had heard him correctly, then politely asked, “What the hell does that mean?”

“That’s what I’m allowed to say,” the Medicare man said.

Really? And nobody wants to fix our healthcare system?

I’m guessing the folks at Medicare have given out so much bad information over the years they’ve been handed a list of talking points, one or the other of which they apply to any given situation. They might as well have said my horse was drinking out of the toilet.

The land of medical reimbursement was proving more inscrutable than I’d bargained for. I changed tactics. I called Nordx. “This test is covered by Medicare,” I began confidently.

“Apparently it’s not,” the Nordx billing lady replied.

“This isn’t my responsibility,” I said calmly.

“Yes, it is,” she replied, equally calm.

“I know I don’t have to pay it,” I said, hoping she’d detect the annoyance in my voice.

“You signed a form saying you would pay everything not covered by Medicare and that is the case here. I’m looking at that form.”

OK, her point.

There was only one other player left: I called my doctor’s office billing department. After about 15 minutes, the chief billing lady and I discovered that, quite by accident if I can use that word, my PSA test had been incorrectly encoded as part of a series of PSA tests for an ongoing prostate problem. And that, Medicare does not routinely pay for. But a single test as part of an annual physical? – yes. The billing lady corrected the paperwork and resubmitted the bill to Medicare so Nordx could be compensated.

Pleased by my own due diligence, I called Nordx back to inform them of the coding mistake and that they could expect to be paid. Triumphantly, not by me. “Why didn’t you just call my doctor when you got my notes,” I asked.

“By law, we’re not allowed to call your doctor,” she replied.

“Why didn’t you call me?”

“We don’t typically call people who refuse to pay their bill.”

I was going to ask her why she didn’t call Medicare but after their explanation, I didn’t see a scoring opportunity.

By the way, the cost of the PSA test was about $65. The cost of three organizations handling a half-dozen pieces of paper over three or four months was probably 10 times that amount. I wonder how long the invoice would have circulated had I not intervened. The point is this. Coding mistakes are a tiny part of what’s wrong with our healthcare system, but this one small maddening example shows how we’re paying way more for paperwork than we are for actual care. Businessweek reports America spends 17.9 percent of GDP for healthcare while the rest of the modern world gets it done for about 6 percent. Are we getting our money’s worth? Not according to a federal interagency group,, that ranks the U.S. 27th of 33 countries in life expectancy. Are we No. 1 in anything? Yup, obesity.

And no one wants to fix this?

You may not like Obamacare or the Romneycare it was based on, but something has to change. The Senate Finance Committee estimates that the average family now pays $1,000 in extra premium costs each year to cover the roughly 40 million folks who have no insurance but get $50 billion in care. If you don’t like the idea that people are being forced to buy health insurance, then you have to support a new law that allows hospitals to turn away people who don’t have policies. And you have to accept watching screaming, dying patients on the doorsteps of general hospitals from coast to coast on The Evening News.

There is some encouraging news. My PSA is very low and that’s a good thing. Glad I don’t have some ongoing, potentially expensive problem requiring, say, repeated PSA tests that apparently Medicare wouldn’t pay for. And there’s this: you could make the entirety of American healthcare solvent in one fell swoop by doing what my friend the nurse wants to do: turn off all life-support machines one month early. An estimated one-half of our total healthcare bill is spent in the last 30 days of life, she argues. Alas, America is first in something else: we’re the only modern country where you’re not allowed to die. Maybe President Obama was onto something with those so-called death panels.

Rick Roberts is a veteran of Boston’s advertising community and the U.S. Army. He resides in Windham. He is author of two books: I Was Much Happier When Everything I Owned Was In The Back Seat Of My Volkswagen, and the recent novel, Digital Darling. Both are available at bookstores,, or visit: