When Dawn Pawelak of Penn Hills had a nerve block injection at her Monroeville doctor's office, she said the charge was $5,623 because the procedure was billed through UPMC Presbyterian Shadyside.
Her insurance covered all but the $250 "operating room service" deductible -- which she is appealing because, she says, she was never in an operating room: "It's ridiculous."
Vivian Trevor of Dormont said she twice had to fork out $40 co-payments for seeing a specialist, even though both times she was treated by a physician's assistant. She didn't see a doctor, let alone a specialist, either time.
Ross resident Dave Allenbaugh said his Keystone Blue Cross Blue Shield insurance coverage waives the $100 co-payment if an emergency room visit turns into a hospital admission. After he spent 36 hours at UPMC Passavant in April when he couldn't catch his breath, his stay was coded as an observation, not an admission, even though he stayed in a patient room and needed a breathing tube.
Yet Robert Mohoska of the city's Allentown section said the 24 hours he spent in UPMC Mercy this spring for a swollen hand was coded as a hospital admission, hitting him with a $4,000 bill. His doctor ultimately told Mr. Mohoska it was only arthritis and sent him home.
UPMC spokesman Paul Wood said federal law prohibited him from discussing any specific patient's case, but "in general, there are lots to different types of insurance policies, and the insurer is the entity patients have payment arrangements with."
Questions about those plans, he added, "need to be addressed by the insurer."
But Highmark spokesman Michael Weinstein said that, in Mrs. Pawelak's case, "It sounds like they're billing it as a hospital outpatient visit, versus a physician's office visit, in which case they would be getting a much higher reimbursement without any additional clinical benefit for the patients."
The differing interpretations between insurer and provider can leave patients confused.
Ernest and Bettye Meinbresse of Mt. Lebanon said they were unexpectedly hit with an $1,360 room co-payment after Mrs. Meinbresse's 10-day stay at St. Clair Hospital for a heart problem in June and August. Their insurance covered the rest of the $34,000 bill, including a $1,152 per day charge for the room, which had a heart monitor and oxygen.
When Mr. Meinbresse called his insurer, "They said, 'That's between you and the hospital.' " St. Clair says the charge is the result of the Meinbresses' lower-premium insurance coverage.
Hospitals are under increasing financial pressure and have to make sure they collect what they are due, particularly with increasing demand for free or greatly reduced care as many people have lost jobs during the current economic downturn.
But, following a recent Post-Gazette story about patients sometimes being charged a "facility fee" in addition to treatment charges, others have come forward with their own experiences with unexpected charges.
While the particulars of their stories varied, there was a common thread: In each case, the patients had higher or additional charges they hadn't expected.
The issue of unexpected charges was first raised in a Sept. 2 PG story in which Diane Aiello of Munhall questioned a $93.50 facility fee on top of her co-payment for a routine physical -- the extra fee charged because the doctor examined her at the Shadyside Medical Pavilion on the UPMC Shadyside campus.
After UPMC threatened to send her bill to a collections expert, Ms. Aiello agreed to a monthly payment plan while she continues to appeal the charge. She also has contacted state insurance officials.
"The vast majority of people don't understand [facility fees], and they're paying something they shouldn't," said Myra Kilgore, benefits manager for the Eckert Seamans Cherin & Mellott law firm, Downtown.
Ms. Kilgore said she had gone to bat with insurers on behalf of Eckert Seamans employees who came to her after noticing the extra charges.
"You can usually get that overturned, but it's such a hassle. You have to find people at the [insurance] carrier who even know what you're talking about, and who know how to fix it," she said.
Many times, she said, the insurer's customer service staff members are not familiar with the issue she's trying to resolve.
"They look at a screen and they tell you what they see. They really don't know what they're looking at or how the whole process works."
Nor does that solve the problem, she said. "They go in manually and adjust it for that person, but that won't stop it from happening next time -- I mean, each and every time, even if it's the same person" challenging the charges.
"I don't know how many people fight it, then end up paying because they're sick of it."
That's what happened with the Meinbresses. Mr. Meinbresse said they considered protesting the bill, except St. Clair offered them a 15 percent discount if they paid within 10 days. He paid but "it really shook me up. It was kind of shocking that I had to come up with another $1,100."
Mr. Allenbaugh initially went to arbitration, but he, too, eventually paid.
"You get tired of writing letters and talking to people."
One who didn't back down was Krystyna Cwiek of South Side Slopes, who said she was charged a $10 fee "because I had the privilege of walking into Falk Clinic" to see a doctor about her asthma a few years ago.
UPMC dropped the charge, she said, after she threatened to "make a fuss."
Steve Twedt: firstname.lastname@example.org or 412-263-1963. First Published September 21, 2010 4:00 AM