69-year-old Virginia woman wins billing dispute with Medicare more than a year after undergoing surgery

Here’s a story about Shirley Klinger, 69, who has been unhappy for more than a year because of a billing dispute with her doctor.

Klinger, a retired legal assistant, has asked Medicare three times about it so far. All of them were turned down. And many phone calls to Carilion’s billing and patient advocacy departments, as well as many conversations between Klinger and the Roanoke Ambulatory Surgical Center, which is a separate organization.

It is on Jefferson Street near where Albemarle Avenue meets Jefferson Street. It is also known as RASC. That’s where the surgery in question took place, and Klinger got a bill for $3,373 that she didn’t expect.

We need to go back a bit to figure out what happened.

Klinger needed surgery in the fall of 2021 to fix a painful tendon that was connected to a hip that had been replaced in 2020. The tendon-release surgery was set to happen at Carilion Roanoke Memorial Hospital in October 2021. At the time, it was supposed to be a “open” surgery, not a “minimally invasive” one that uses a scope.

But Klinger said that about a week before the surgery, a Carilion representative called her and told her that the surgery would have to be moved. Because of the COVID-19 pandemic, there wasn’t enough staff in the hospital’s operating rooms, the Carilion representative told Klinger.

The Carilion representative also told Klinger that the surgery could be done at RASC, which had an opening on November 4, 2021. Klinger said yes, and the rep set up a date for Klinger. She showed up at RASC on the right day at 6 a.m.

Instead of “open” surgery, the surgeon did the surgery with a scope. It worked out well, and Klinger was back home that afternoon.

Unfortunately, Klinger fell and broke three bones in her ankle just 15 minutes after she got home on November 4. Ouch!

Because of this accident, Klinger had to have surgery on her ankle 10 days after she had surgery on her tendon. She now has screws and a metal plate in her ankle.

As you might expect, Medicare and Klinger’s Medicare supplement insurer sent her a lot of explanation-of-benefits forms over the next few months. Those came out of both processes. They didn’t get much of Klinger’s attention until January 2022.

At the end of that month, RASC sent Klinger a bill for $3,373. Klinger didn’t believe it. She didn’t think she had to pay it because she had Medicare. But Medicare would not pay for the bill from RASC.

Klinger isn’t sure how many phone calls she made to Medicare, Carilion’s billing department, Carilion’s patient advocacy staff, or RASC. Klinger said that there were many, many, many calls. She also tried to get help from the Local Office on Aging and the State Corporation Commission, but neither could help her.

People she talked to told her over and over that Medicare wouldn’t pay because of a mistake in “medical coding.”

“I don’t know how many times I talked to Carilion’s patient advocate department,” Klinger said. “They told me they couldn’t do anything.”

Klinger told me that one time, a Medicare representative told her that the bill would be paid. But later, another Medicare representative told Klinger that someone else in Medicare had changed their mind about covering him.

By the spring of 2022, Klinger had made two appeals to Medicare, but both were turned down. For Klinger’s third appeal, her doctor at Carilion wrote Medicare a two-page letter. But neither of those things helped. Medicare also turned down that appeal.

Klinger found out later that Medicare would have paid for the charge from RASC if her surgery had been done “open” instead of with a scope. But Medicare didn’t pay for Klinger’s surgery at RASC because it was minimally invasive and done with a scope.

“This kind of [minimally invasive] surgery was not approved by Medicare to be paid for at [RASC],” Klinger explained. Klinger also said that no one told her about this difference ahead of time or asked her to sign a form promising to pay what insurance wouldn’t.

Klinger told me, “We pay our bills.” “I’m happy to pay for something I really owe.” She also said that she and her husband could have at least planned for the facility fee if she had known about it before the surgery.

“I was never told that any of this would happen,” Klinger added. She thought that Medicare would pay for everything.

“I was never given the necessary release to sign saying I would be responsible for the debt,” Klinger told me in an email.

Next, Klinger and her husband, who is also retired, asked RASC to cancel their debt because they only had Social Security and couldn’t pay the fee.

In September, RASC cut it in half, bringing it down to just over $1,600. But Klinger still didn’t think she should pay, so she didn’t. And on January 18, a bill collector sent her a letter demanding that she pay the $1,600.

On January 19, Klinger called me and told me the story above. I called Hannah Curtis in the media relations department at Carilion and asked her to look into it.

Curtis did. But because of a federal privacy law, Carlion could not talk about Klinger’s case in detail with this newspaper unless Klinger gave Carlion written permission. About a week went by. So, we’re up to last week.

On Friday, RASC called Klinger to let her know that the $1,600 debt had been cleared. This email from Klinger told me that.

She wrote, “Mr. Casey, you’re a miracle worker! Roanoke Ambulatory Surgery Center just called me to tell me that my bill has been paid. I have a zero balance. I’m in shock right now, to be honest. “At last, after a year, I have a plan!”

I am still not sure exactly how that problem was solved. Part of it might have to do with the fact that RASC does business with Carilion Clinic.

Even though Carilion Clinic is a non-profit organization, it owns or shares ownership of some businesses that make money. Curtis said that RASC is one of these. She said that “a part” of the surgery center is owned by Carilion. And Medicare considers RASC separate.

In 2009, this newspaper had a story that said Carlion owned 50% of RASC. There are 12 doctors who own the other shares. In a brochure that RASC gave Klinger, they are all named. (The name of her doctor wasn’t on that list.)

Curtis also said that Klinger’s doctor planned to do a “open” tendon release procedure at RASC after the one at Roanoke Memorial Hospital had to be canceled.

“However, during the procedure, the surgeon decided that the best way to help the patient was to change the way he or she was doing things,” Curtis said. And instead, a scope was used. “Because of that change, Medicare no longer paid for the procedure to be done in an outpatient surgery center.”

And that’s how Klinger ended up with the $3,373 bill, and why Medicare refused to cover it.

Curtis told me, “Given the facts of this case, RASC has taken Ms. Klinger out of the middle of the complicated relationship between the provider and the payer by making an administrative change that frees her from any responsibility for payment.”

“We’re continuing to collaborate with the Roanoke Ambulatory Surgery Center (RASC) to review what happened and determine if it can be avoided in the future,” Curtis added.

That would be the best result, especially for any Medicare patients who might want to have surgery at RASC in the future.