Sharing Healthcare’s Dirty Little Secrets

secretI’ve just written a post at about my recent mammogram experience where the breast center I’ve gone to for more than a decade managed to dissolve my trust of their service in the span of one phone call.

Is it possible that they were being honest and I have no reason to lose my trust in them? Yes, of course. Maybe I’ve jumped the gun – or maybe not. But it doesn’t really matter.

Because whether they deserve my distrust or not, I will never trust them again. No, not a chance. (Just because I’m paranoid doesn’t mean they aren’t out to get me.)

And so it struck me as I was writing that post that the very fact that I have become so distrustful of them suggests a place where advocates can actually create more trust for themselves.


By sounding the warning bells. By sharing the system’s dirty little secrets.

I expect that as time goes on and out-of-pocket costs in the form of co-pays and co-insurance go higher, and the fact that providers are squeezed more and forced to find new revenue streams, we will begin to see more and more ways patients are asked to pay for things they should not have to pay for. The ripple effect can be enormous. And you can be the one person who warns your clients about the possibilities, saving them money, grief, and potential problems down the road.

In my case I was being asked to return for duplicate mammogram images, not because there was anything suspicious about the first ones, but because, supposedly, the technician did not do her job correctly. I will always believe that such a claim is a handy dandy way to allow the testing center to bill insurance twice (keeping in mind that, due to the preventive test section of the new Affordable Care Act, they aren’t allowed to charge patients a co-pay or co-insurance). Of course, anyone involved would deny that’s what they are trying to do. A prime dirty little secret.

I refused – because I don’t want my insurer to pay twice, but even more so, because I don’t want my records to reflect that they found something suspicious – which is what they would have to claim (in the form of CPT codes) in order to get their second reimbursement. And imagine the things they could get my insurer to pay for after that!

These are the secrets you can share with a client. In effect, you are providing them with some “inside information” on how healthcare works that they probably don’t suspect. The fact that you have shared a confidence is something that truly garners trust.

Repeating tests is one problem you can call their attention to. Running unneeded tests is another. (Check out Choosing Wisely). If you know of others, I invite you to add them to the comments below.

Sometimes the best way to build your practice is based on wise counsel a client would not expect – and these sorts of warnings fall into that category. By exposing such dirty little secrets you are benefiting your client, and your practice, too.



11 thoughts on “Sharing Healthcare’s Dirty Little Secrets”

  1. This is one of the many issues that our organization, Patient Advocate Services, Inc. is addressing. I give presentations to local groups on many “dirty little secrets” that the general public is not aware of and should be. We are all paying a lot of money for dupicate tests, co-pays, out-of-network charges, etc that we should NOT be paying.

  2. Pamela Barklow

    Your article really struck me as a probable case of miscommunication. I spent many years in the Imaging Departments (formerly called Radiology) of hospitals and have had the opportunity to experience mammography from both a technician’s point of view and as a patient. I also assisted in many breast ultrasound exams and breast mass localizations before going into surgery.
    I’d like to offer a different perspective regarding calling you for a ‘repeat because the technician didn’t do her job.” In my experience, if it were a case of the technician not performing an exam properly, there would be no charge for your return exam.
    You have no doubt experienced all the little ‘adjustments’ and positioning by the technologist to get the views needed for the radiologist. It is difficult to get the chest wall on the CC (cranio-caudad) view because of the rib cage, so it is important to show the chest wall on the lateral (side) view.
    In radiology, you must have 2 views in different planes in order to show the location of a mass, just like a sonar screen, or triangulating the position of a cell signal. Our breasts are 3-dimensional. If the radiologist feels he doesn’t have enough information, or a possible mass shows up only on one view, we must try to get an additional view to localize the mass. It is quite common to be ‘called back’ for additional views. They are NOT the same views taken twice.
    You shouldn’t feel like they are just trying to bill twice. That extra view that you come back for may answer the question of a possible mass or not. I have spent many hours assisting in breast localization procedures which would be like ‘finding a needle in a haystack’ if you didn’t know the relative position of a mass to biopsy, or even aspiration of a breast cysts, which is also quite common. There are many reasons for additional views, and an incompetent technologist is rarely one of them.

    Been there, done that,
    Pam Barklow
    Edmonds, WA

    1. Hi Pam – a good perspective, thanks. You’ll see that I mentioned the possibility that I leaped to conclusions in the post above.

      If you read the accounting of the conversation, you’ll find more information there.

      Of course, I couldn’t reiterate the entire conversation here, but there were definitely other indications that something was amiss, including the fact that I asked the radiologist how often people are brought back for just such a case. She told me they have been encouraged recently to bring people back more frequently. And she was uncomfortable giving the answers.

      So, a “probable miscommunication” – I’m not sure it was probable, but I do allow for it being possible.

      However, let’s hope you are right. But let’s also realize that there are many MANY ways patients are being overtested, too often retested, exposed to too much radiation, etc.

      It’s an opportunity to keep our clients on their toes (as stated above.)

      No matter whether I drew the right conclusions or not, we must always be vigilant and stay on our toes.


  3. I read your post about your experience with rising concern. First, that you?d experienced the kind of scare we all hate, especially if there’s been a previous reason to heighten our fear of dreaded news. I’m sorry about that.

    Second, that you?d accepted the reason to return as a mistake on the technician’s part. If there were going to be bad news or a concern requiring another look, they were not going to convey that on the phone ? nor should they. While it might have been better for them to ask you to wait until the radiologist checked to see if further pictures were needed the first time (as they do at my community hospital women’s health center), it in no way suggests the institution was trying to increase revenue in such a ham-handed way.

    Although we?ve all read reports of doctor-owned clinics or outpatient centers that have been busted for corruption, that should not lead us to treat all healthcare providers as crooks just waiting for the next patsy. The radiologists might be on staff and salaried and have no skin in the revenue game. That was why the radiologist in your situation had no clue about the billing.

    And that leads me to my major concern: As we work with clients through the complicated maze of the healthcare ‘system?, it’s important to watch out for them and ask assertive questions. We must, like good consultants, enter the system where it is and work to achieve understanding with the people who are trying to offer their services, while at the same time not acting like adversaries. That will get us shut out quickly and harm our clients more in the long run. It is this philosophy that led my colleague and I to call ourselves ?healthcare navigators? not advocates.

    A number of people are entering this very young field because of terrible experiences either personally or with a family member. As a nurse, I know what can happen when no one is talking with the care-givers (and my fellow nurse friends and I have had a pact to be there for each other long before patient navigators were thought of). It is helpful to keep in mind that not all experiences are or need be terrible if someone is watching and asking questions and not assuming the worst immediately. I?ve been on both sides and it really feels terrible when your caring efforts are seen as part of some nefarious motive.

    Something to think about when we enter the healthcare system.

  4. ” Remember, the healthcare system is set up to make money from unsuspecting patients ? and so it seems they did a good job of making money from you and me.”

    Trisha, this is a reply from you to another poster on this site. I am becoming more convinced that that kind of attitude is damaging to clients and our endeavors and also that I’m not inclined to be associated with a group that holds such a view. I’m open to hearing other points of view…

  5. Leslie,
    I understand your position and also believe there is a huge amount of misunderstanding in the entire healthcare system. But I also must repeat that in a huge number of cases additional tests, additional hospital days are only ordered to get more money for providers. This is a fact of the dysfunctional system that we all have to deal with. To NOT bring this to the attention of our patients/clients is doing them a disservice.

  6. Kim, I do think a lot of error in the system has come from the coding and billing ends – I’m hopeful the EHR will eliminate much of this. And, perhaps, additional tests are sometimes ordered because of the state of healthcare litigation in the US (and I’m aware of this as I also do legal nurse consultant work).
    But I would need to see the evidence on which you base your statement, ‘But I also must repeat that in a huge number of cases additional tests, additional hospital days are only ordered to get more money for providers.’ Show us the research, please.
    For those of us who accompany clients to appointments and serve as point persons during hospital stays, I continue to maintain that holding those attitudes will serve no good purpose and get your efforts booted out quickly to the detriment of all of us.

    1. Leslie – what you probably don’t know is that my roots all come from the patient empowerment world; that’s what spurred me to found the Alliance and AdvoConnection. It’s also the world I still spend at least half my time addressing. (see Patient Empowerment or my book on the topic.)

      As a result, I have an extensive network of industry people (providers) who provide me with all kinds of intelligence as to what is going on in the system. One of the themes that has developed over time is what I call “Newton’s Laws of Healthcare” – which says that for every action in healthcare, there is an equal and opposite reaction.

      In this case the action is this: that due to part of the new ACA (Obamacare), patients are now provided with a long list of “free” preventive exams.

      But of course, as intelligent adults, we all know that there is no such thing as “free” – and the difference will be made up somewhere. So the Newton-like reaction is this: that tests will be run a second time (this time for reimbursement) and/or additional tests will be requested and prescribed (more expensive ones, charging more than was charged before, reimbursed at higher rates) – or any of a dozen other ways the cost will be made up. In fact, one of my insiders tells me that the ‘free’ tests have actually provided a boost to income because they are now being used as ways to get patients in the door, patients who then “need” more lucrative testing. (Scary, I know.)

      I don’t make this stuff up. This is information that has been provided to me by people who are in the trenches, doing the work, being told how to do it differently in reaction to the “free preventive screenings.”

      In my personal case, and partially to your point, I have no idea whether that’s why I was called back. It’s an educated guess. Contrary to your statement, however, yes the radiologist confirmed that I was being called back because the technician had not done the job right to begin with. For all I know she was simply throwing the technician under the bus…. It doesn’t really matter, though.

      Perhaps the most important point here is your statement, ” As we work with clients through the complicated maze of the healthcare ‘system?, it’s important to watch out for them and ask assertive questions. We must, like good consultants, enter the system where it is and work to achieve understanding with the people who are trying to offer their services, while at the same time not acting like adversaries. That will get us shut out quickly and harm our clients more in the long run.”

      You are absolutely right about that, and I am not for one second suggesting that advocates or navigators take an adversarial approach.

      What I AM saying is that we owe it to clients to question repeated tests to be sure they are being done for the benefit of our clients and not for the benefits of someone’s wallet, or covering someone’s backside. I think it’s naive to think that OUR clients won’t be put into these situations going forward. And we don’t serve them well if we don’t accommodate for the possibility.

      And I would add that “trust but verify” is always a good approach.


  7. This scenario is already rampant. At the SNF my mother was in, they wanted to perform all sorts of diagnostics that had just been done at the hospital. I explained they should contact the hospital for the copies/ reports for those same tests performed just a week earlier. Sadly many patients don’t understand that they are allowed to express their opinion or question the medical staff. Education is key.

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