An emergency room story to make anyone ill

March 26, 2012

By Attorney David Engler

Have you ever received an Explanation of Benefits letter from your insurance provider and cannot figure out what you owe? You are not alone in deciphering a hospital bill. At,0,6538717.column/ Steve Lopez describes how a father received a $5000 dollar emergency bill for his daughter’s tummy-ache!


So they went to Providence Tarzana Medical Center’s emergency room, where Moser handed over his insurance information. He had lost his job in TV production, and later bought his own medical insurance. To keep the monthly premiums manageable, he went for a plan with a $5,000 deductible.

“I kept asking, ‘Is this really necessary?’ ” said Moser, who first questioned the emergency room staff about the need for an IV drip to administer a saline solution.

The staff agreed not to do the saline solution. After some blood work, the doctor recommended an ultrasound, which Moser questioned. He relented, though, when the doctor said it wasn’t absolutely necessary but would rule out anything serious. And it did, so Ella went home with what was diagnosed as nothing more than an upset stomach, from which she quickly recovered.

But when the bill arrived, John Moser felt a sharp pain in his own gut.

The cost for just walking in the door of the emergency room? That came to $1,288. The ultrasound nicked him an additional $1,135. A comprehensive metabolic panel (blood analysis) was billed at $1,212.

Moser was also charged $158, accidentally, for the saline solution he had turned down. The total came to $4,852.55, not counting separate bills that would arrive later and total nearly $1,000, including $540 for pathology and $309 for the doctor.

“I was shocked,” said Moser.

The first bill, $4,852.55, was confusing, as medical bills often are. It said “your health plan has recently made a payment on your account.” It said the balance, $2,571.85, “is now your financial responsibility.”

When Moser mentioned the bill to his father, Marvin Moser flipped.

“Yes, the fees in ERs are off the wall all over the country,” the professor of medicine told me, but he found Tarzana’s to be extraordinary. “The one thing that stands out, beyond belief, is $1,212 for a metabolic panel.”

That’s a test, Dr. Moser said, in which a technician draws blood for chemical analysis, and it takes just minutes. Moser questioned not only the charge, but the usefulness of the test in his granddaughter’s case.

Out of curiosity, I went online to see what a lab might charge for a comprehensive metabolic panel.

Any guesses?

Some labs advertise prices as low as $39.

Glenn Melnick, who teaches hospital economics at USC, was not surprised.

“By and large, these prices are fictitious numbers,” said Melnick, who argued that Tarzana and most other hospitals routinely charge astronomical fees, especially for emergency room services.

Of course, and it’s all part of a years-long game in which the charge for service, the true cost of the service, and the acceptable payment are in three different orbits. And that doesn’t even take into account how the charges are adjusted up or down depending on who’s paying them and whether they have worked out a deal. How can patients hope to make sense of such an indefensibly convoluted system?

Starting Monday, President Obama’s healthcare reform act will get a hearing before the U.S. Supreme Court. But how can you have an honest conversation about soaring healthcare costs and health insurance, Dr. Moser asked, without addressing the maddening fictions built into the system? Patients seldom know in advance what they are being charged, he said, and many later find themselves in “medical bill bankruptcy.”

Melnick said hospitals argue that they lose money providing service to the uninsured, and by not getting reimbursed enough for Medicare or Medicaid patients. There’s some truth to that, Melnick said, but prices are set artificially high to help balance the books on the backs of paying customers. In the case of a $1,200 charge for entering an emergency room, Melnick said, the Medicare reimbursement is likely to be $300 or less, and far closer to the hospital’s true cost.

“Hospitals have figured out they can rapidly increase charges in the ER,” Melnick said, “and that will lead them to get higher amounts even from insurance companies they negotiate with.”

This is a very big deal, Melnick said, because half of all patients admitted to a hospital in California go in through the emergency room. Melnick said there’s also been a huge increase in the number of patients who lost group coverage and purchased individual plans with high deductibles, making them more vulnerable to exorbitant charges.

“More and more, people are seeing their deductibles eaten up on one visit.”

Melnick directed me to a state website ( where every California hospital lists its fees. I did a little surfing and it appeared that the comprehensive metabolic panel for which Tarzana charged $1,212, Cedars-Sinai Medical Center lists a price of $786.45 and Ronald Reagan UCLA Medical Center charges $350.

A Tarzana spokesperson, Patricia Aidem, sent me a statement defending Ella’s care. “A child’s life was in our team’s hands and they acted accordingly…” said the statement.

It added that Providence hospitals spend millions each year on charity care for those who can’t pay. Aidem also provided data from the state website showing higher fees at other hospitals than Tarzana charged in the Moser case, including $2,678 for an abdominal ultrasound at West Hills Medical Center and a $4,413.24 emergency room visit at Cedars.

But that’s just the point. The price swings are so dramatic that they seem arbitrary, if not indefensible. I can’t predict how the Supreme Court will rule on healthcare, but I’m prepared to issue my judgment: It’s a mess.

(Look for a column in the next week on how the bill for Ella Moser’s tummy ache was settled and tips on how to avoid going broke from a minor medical emergency.)

Attorney David Engler
Phone: 330-729-9777 Attorney Engler’s website
Areas of Practice: Family Law, Elder Law, Domestic Relations, Bankruptcy, Criminal

Also published on on March 26, 2012 and Family Fault Lines Blog

Keeping Track of Your On-Site Visits

September 14, 2011

By Attorney David Engler

One of the most important jobs of a guardian is to keep track of the times you visited your ward at a nursing or group home. Just last night I was visiting my own mother at a rehabilitation facility. Now while she seems to be completely competent at age 82, I can see the difference in treatment because the staff knows I am a lawyer and involved in the guardianship business. Most importantly I am keeping track of what I am seeing and letting them know that I am. My mom has complained about not getting her medications at the right times and about rude treatment by an aide. Her roommate confirmed the complaints.

It is remarkable how some staff that work at nursing homes do not seem to like their jobs and treat all patients like unruly children.

Well, they should be listing the complaints they receive directly from the patients on their charts. They do not! It is information that might show a pattern of neglect and therefore better not to list. But the fear of litigation is a powerful deterrent and if you demand that your complaints on behalf of your ward be documented and that you are recording the same, your client will get better care.

My Mom hit the nurse’s button and was not supposed to use the rest room without assistance. The response took more than 20 minutes. Now she is on a diuretic and it is hard to wait. The aide finally showed up and said, well just do it in your bed. You have to be kidding! She wasn’t! Believe me, these understaffed and under trained statements are coming out every day to our wards who find themselves relying on the care of others. Let the facility know up front that you will document the issue in your own case notes.

Our software ( allows the guardian to keep track of case notes and these notes are searchable. Contemporaneous notes are admissible as business records if litigation is needed in the future. We have to put the pressure on the residential care-givers to keep them honest and accountable.

Vary the times you come to visit so your schedule is not predictable. If they know you show only at 4 P.M. then maybe they will not bathe your ward until that time. Do not be shy about letting the residential care facility know that your job is as an advocate on behalf of your ward. Let them know that you keep electronic records even if they do not.

Attorney David Engler
Phone: 330-729-9777 Attorney Engler’s website
Areas of Practice: Family Law, Elder Law, Domestic Relations, Bankruptcy, Criminal

Upcoming Holidays: Good Advice for Visiting Loved Ones with Dementia

September 9, 2011

“I read this great article about holiday visiting in the Columbus Dispatch” – Attorney David Engler

Good Advice for Visiting Loved Ones With Dementia
By Misti Crane

This upcoming holiday season of gathering, reminiscing and tradition also can bring sadness and uncertainty for those who love someone with Alzheimer’s disease or some other form of dementia.

To make the most of holiday visits, caregivers and other relatives and friends should accept what can’t be fixed and learn to offer support and bring joy to those affected by the disease, experts say.

During visits, “you have to learn to suppress any feelings that you have, put a big smile on your face and try to be as cheerful as you can,” said Dr. Leopold Liss, medical director of the Columbus Alzheimer Care Center.

One in 10 Americans 65 and older suffers with dementia. It affects almost half of those 85 or older, according to the Alzheimer’s Foundation of America. Alzheimer’s disease is the most common form of dementia.

People are prone to over-explaining reality when an evasive, yet truthful, answer would be best, Liss said.
Laralyn Sasaki, who lives in the Short North, said that her visits with her grandmother, who had dementia, improved significantly when she learned to answer questions that way.

“When she asked where her husband was, who had passed away several years before, we’d say, ‘You know, we haven’t seen him today’” said Sasaki, whose grandmother, Thelma Townsend, died three years ago at 97.

Learning to avoid correcting the person with dementia is essential, said Mari Dannhauer, program director at the Alzheimer’s Association of Central Ohio.

“We tell caregivers they’ve really won their last argument, because the person with dementia is not able to be rational in our world so, we kind of have to jump into their world.”

Insisting that someone remember your name is useless and potentially damaging, Liss said.
“You have to respect the fact that this is their reality. Don’t try to jerk them out of it because it might have negative results,” Liss said.

Helping also can mean avoiding things that create frustration.

Sasaki said she and her mother learned to tune into nature shows or old, happy movies rather than channels featuring current events and political candidates her grandmother didn’t recognize.

Her advice to others dealing with dementia is to visit loved ones rather than staying away out of fear of awkwardness or tension.

Sasaki was part of a team of people who volunteered their time recently to produce DVDs and CDs that feature Liss and offer caregivers advice.

At the holidays, caregivers should know that things don’t have to be perfect, nor do they have to be the same as every other year, Dannhauer said. Changing a home-cooked holiday party into a potluck can ease anxiety. And having family members visit in shifts rather than all at once can help, Dannhauer said.

She recommends involving the person with Alzheimer’s disease in activities such as singing carols or wrapping presents rather than assuming that they can’t or don’t want to participate. Interacting with children can be uplifting, and smiles and embraces are almost always a good thing, Liss said.

For information about central Ohio support groups and other resources for friends and family members of someone who has Alzheimer’s, call 1-800-272-3900 or visit

For information about The Art of Caring DVDs, go to

Attorney David Engler
Phone: 330-729-9777 Attorney Engler’s website
Areas of Practice: Family Law, Elder Law, Domestic Relations, Bankruptcy, Criminal

Who You Calling Sweetie?

September 5, 2011

By Attorney David Engler

Have you ever taken an aged client or your parent to the Doctor’s office and the doctor or nurse refers them as sweetie or sugar or some other term of endearment?

I know the doctor is trying to show compassion and connection but the opposite often occurs. It is a way of saying I don’t take you all that seriously and need to address you in a patronizing way; seniors get offended by health care professionals who treat them like children. A male doctor would not refer to a 36-year-old female client as sweetie and he should not refer to an 83-year-old female any differently. It is the subtle use of words that convey a relationship that is not equal.

The people we bring to their doctors might be frail and fearful but most are of sound mind and understand that they are being talked about in their presence.

I am suggesting to all well-intentioned professionals to refer to the elderly in the more respectful manner of Mr., or Mrs. or by their first name if they have a solid relationship.

Never ask the son in the room if the Mom is acting confused when the Mom is sitting right there. It feeds into their sense of hopelessness that their guardian or child is the only one that can be trusted with medical questions. There may be a time for such questions but they should be done outside of the presence of the patient.

You might order your eggs at a roadside diner and call the waitress sweetie, but you should never call an aged patient sweetie. They know as much about their condition as the doctor does and they have seen more of life, like the ravages of war, like raising a family, or making tough decisions at work. Always err on the side of treating our elders with respect.

Attorney David Engler
Phone: 330-729-9777 Attorney Engler’s website
Areas of Practice: Family Law, Elder Law, Domestic Relations, Bankruptcy, Criminal

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