Perhaps the fees charged to me are not outrageous with respect to those currently being charged for hospital employee physicians, but that is a separate issue that I am not addressing here since all information available to me representing Dr Cenizal's status (until the end of the first office visit when I asked her how we were to pay and she stated that she was a CGRMC employee and had no idea what fees were charged for her services) indicated to me that she was in private practice and would charge fees according to that standard in the Casa Grande area, rather than some different standard of fees charged by CGRMC for its employee physicians. In fact, if I had any reason at all to suspect that she was an employee of CGRMC rather than in private practice, then I would certainly have required her fee structure before beginning the first visit.
We had taken the time to research online what the medical profession's main representative group has published regarding physician's fees and Paul provided a quote in his response to Karen Francis, from the AMA's policy regarding "excessive fees":
"A fee is excessive when after a review of the facts a person knowledgeable as to current charges made by physicians would be left with a definite and firm conviction that the fee is in excess of a reasonable fee. Factors to be considered as guides in determining the reasonableness of a fee include the following: (1) The difficulty and/or uniqueness of the services performed and the time, skill, and experience required (2) The fee customarily charged in the locality for similar physician services (3) The amount of the charges involved (4) The quality of performance (5) The experience, reputation, and ability of the physician in performing the kind of services involved (II) Issued prior to April 1977; Updated June 1994."
The fact that Dr Mary Joseline Cenizal was a hospital employee and not a physician in private practice had been a great surprise to us at the end of that first visit. There was absolutely no indication of this in her office and this fact along with several others was clearly pointed out in Paul's reply:
1) A Yellow Pages listing under physicians with the business name "Casa Grande Infectious Diseases" and no reference to CGRMC.
2) A business card on the receptionist window ledge with the same business name and no reference to CGRMC.
3) Letterhead and envelope return addresses indicating the same business name and no reference to CGRMC.
4) An office external door stating the same business name with no reference to CGRMC.
There is nothing stated inside Dr Cenizal's office nor on any forms that I was given to indicate that she is anything but a private practice physician sharing an office with a neurologist, Dr Harry S Morehead, in a building close to CGRMC (similar to how Dr Fieldstone's office is located).
5) A statement from Resolutions Billing asking for payment to Dr. Mary Joseline Cenizal with no reference to CGRMC. The fact that CGRMC uses a billing service separate from their own adequate in-house service, again suggests intent to misrepresent the status of Dr Cenizal (and likely many other CGRMC employee physicians) as being in private practice.
6) Just yesterday evening, a phone call about that statement from a "Kimberley" at Resolutions Billing, who first stated she was phoning from Dr Cenizal's office, later admitted that she was with Resolutions Billing, but was still adamant that Dr Cenizal was in private practice and only related to CGRMC by having staff privileges there. I am not accusing Kimberley of lying; I think that she did not realize the true status of Dr Cenizal as an employee of CGRMC rather than a private practice physician as many others of Resolutions Billing's clients may be. Kimberley may also have been instructed to state to patient/customers that she was "from Dr Cenizal's office", but I do fault both her for accepting such a dishonest task and Resolutions Billing for giving such an instruction to an employee.
Paul acknowledged to Karen Francis that he did not know the legal status of a hospital's requirement to be part of the Medicare/Medicaid systems. However, and as he wrote her, if participation in the Medicare/Medicaid systems is voluntary (as it is for physicians), then Casa Grande Regional Medical Center has *chosen* to be part of them and by charging higher fees to everyone else to offset such lower payments is effectively forcing all non-Medicare/Medicaid patients to make charity payments. Even if CGRMC is legally compelled to accept Medicare/Medicaid patients (and by what law - perhaps to qualify for some government funding of some kind?), what Karen Francis failed to state and may not even think about, is that the very same government, that she, in essence, maligned, also enforces the special status regulations under which hospitals and physicians operate. He specifically pointed this out and added:
Without such licensing and myriad other regulations (greatly restricting entry into and availability of a variety of offerings of such services), hospitals and all health care workers would need to compete in a truly free market in health care services. This would both greatly lower the prices of services and bring many new choices into the marketplace. Worst of all, in the current monopolized bureaucratic health care system, is that there is virtually no industry regulating feedback on procedures and prices by the individual patient/customer. The trend toward universal health insurance coverage is greatly exacerbating this lack of any feedback to reign in the use of medical procedures that are mostly advised without any regard to cost relative to benefit. As a self-pay health care client, I am trying to do my part to give this necessary feedback to this runaway system.
Correction was in order for Karen Francis' conclusion that Paul's decline to apply for government assistance and hospital charity write-off, if the former were denied, was because "it was not a matterof financial hardship." Paul made a very clear statement that our financial status had no relevance to his original and continuing complaint:
Nothing that I said indicated anything of the sort. Whether or not there is any "financial hardship" is both totally irrelevant to my dispute here and *only my judgment to make*. It has nothing to do with any of the points I have raised.
As stated above, Karen Francis had claimed in her message that "we have very few complaints from other patients regarding the charges from our physicians". The obvious answer to this is, first, that the vast majority of people are fully insured and pay no attention whatever to any actual underlying costs of medical procedures that they have done, and second, that most of the rest are indigent and unquestioning because they are happy to get whatever they can. Paul added to these points:
How many patients do you have who have *intentionally elected* to be self-pay after analyzing the cost/benefit parameters related to the decision and who therefore care about the cost/benefit ratio of the procedures that are suggested to them, rather than simply being insured through employment or otherwise because they could afford it?
Karen Francis' decline to offer anything more than the 20% off the current bill (200% of the Medicare accepted fee) was met with Paul's reply:
And I serve notice that I am declining to pay Dr Cenizal's bill (actually CGRMC's bill) for services until I get satisfactory answers to all my questions and some changes in the policy of CGRMC with respect to its misrepresentation of the practice status of Dr Cenizal (and likely other employee physicians.This message of Paul's then included the additional points that he raised in his previous correspondence to which he required a response. He closed with the request that Ms. Francis "please pass [this matter] on to CGRMC higher management" if she "can not or will not deal with this." The receipt of the email from Karen Francis the next day, February 14 2008, was not a surprise, given the tone of the initial message from her.
Karen Francis failed to address any of the particulars of Paul's message and instead took a stubborn stand that simply because she did not "continuously have patient complaints", then the charges were not excessive. This individual apparently cannot fathom Paul's simple explanation for why she has no complaints from patients. Either that or she wrote what she did simply because she thought that was the way to bully a patient. It is also quite possible that hospital lawyers advised her not to address any of Paul's complaints, but simply to ignore them and demand payment, again claiming the fees to be not excessive.
I and Paul discussed how to proceed, and the following is the text of what we sent along with a check made out, as directed on the bill, to Dr Mary Joseline Cenizal.
As detailed on the enclosed email correspondence with Karen Francis, Chief Financial Officer of Casa Grande Regional Medical Center (CGRMC) all indications were that Dr Cenizal was a private practice physician, rather than an employee of CGRMC.Therefore, the enclosed payment of $31.20 itemized as follows is based on fees obtained for private practice physicians located immediately next to CGRMC and having staff privileges there. The level numbers reflect length and complexity of the visit. The number that I have assigned is based on a comparative visit to a private practice physician.
[Itemization omitted]
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