Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

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doug1022
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Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by doug1022 »

Hello,

My 13 year old son had a tonsillectomy a month ago, and the hospital discharge notes furnished by the surgeon & his staff included pain management instructions that resulted in elevated acetaminophen levels, which necessitated a subsequent overnight admission to the hospital (overdose protocol, bloodwork, additional dr visits, etc).

The crux of the issue is that the pain management instructions that were provided to us did not articulate a daily limit that we should avoid exceeding. We medicated our child per the instructions, and as a result, he received too much acetaminophen each day for four days. Once we finally figured this out, we brought him back to the hospital for bloodwork, at which point it was determined that his levels were too high and he needed to be admitted on an OD protocol. The surgeon has admitted that the discharge notes were "too vague."

That said, my son is fine now and will not endure any long-term consequences as a result of this error - thank god.

However, we are just now starting to see the medical bills for these additional OD services which we feel are not financially responsible for. Had the pain management instructions been clear, my son would not have had to be admitted and these services would not have been needed. We have reached out to our insurance company hoping that they would act as the conduit between the Surgeon (who was at fault, and not involved in the OD protocol) and the hospital who provided the services. The insurance company has refused to take a position in this matter.

What are our options? Do we work directly with the surgeon's billing office? Do we simply refuse to pay?

Sorry, we've never been down this road before and are looking for some guidance.

Thanks
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njboater74
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by njboater74 »

You might want to discuss with an attorney.

Did the instructions on the discharge notes indicate something that would be contrary to the warnings on the bottle of acetaminophen? Aceteminophen has known risks, and those are always found on the bottle. If they instructed you to use a dosage in excess of the directions on the bottle, that would warrant concern.
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dm200
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by dm200 »

Glad your son is OK.

Good luck in your efforts. I doubt you will get anywhere. From your narrative, the providers of the services are not the folks that provided the "vague" instructions leading to the significant problems.
Hikes_With_Dogs
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Hikes_With_Dogs »

Time for an attorney if you really do not want to pay.
Rupert
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Rupert »

What kind of hospital was it? Possibly if it's a university or state-owned hospital, you might have some luck negotiating with the hospital. An anesthesiologist once knocked my child's tooth out during an ear surgery at a state university-affiliated hospital, which resulted in a hospital stay that had not been anticipated or pre-approved by my insurance company. In that case, the hospital ate the charges, and we never got a bill. But, if you're dealing with a private outfit, I'm afraid you need a medical malpractice attorney. This wasn't the hospital's mistake, and so I doubt a private hospital will be willing to forgive those charges.

Please disregard the PP's comment about the instructions written on the bottle of Tylenol. Your doctor's instructions trump the instructions on an OTC bottle.
Allixi
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Allixi »

I don't think it would hurt to talk with the billing office but unless they specifically told you to "ignore maximum dosage written on the bottle" I don't think you have much grounds to get out of the bill. All medications have efficacy and toxicity depending on dose, I don't think it should be expected of doctors to remind every patient of this in every instance.

Edit: now that I read your post again, I think you have more of an argument if you followed their instructions to the letter. They might be willing to reduce the bill if you talk to them.
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MilleniumBuc
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by MilleniumBuc »

Definitely reach out to attorney. Unfortunately the hospital provided a service that should be paid. The crux is if it's you or the prescribing Dr is ultimately responsible for that bill. You have an opinion and the Dr has an opinion, and I think that is way the insurance company is staying on the sidelines on this one.
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njboater74
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by njboater74 »

Rupert wrote:What kind of hospital was it? Possibly if it's a university or state-owned hospital, you might have some luck negotiating with the hospital. An anesthesiologist once knocked my child's tooth out during an ear surgery at a state university-affiliated hospital, which resulted in a hospital stay that had not been anticipated or pre-approved by my insurance company. In that case, the hospital ate the charges, and we never got a bill. But, if you're dealing with a private outfit, I'm afraid you need a medical malpractice attorney. This wasn't the hospital's mistake, and so I doubt a private hospital will be willing to forgive those charges.

Please disregard the PP's comment about the instructions written on the bottle of Tylenol. Your doctor's instructions trump the instructions on an OTC bottle.
If the instructions on the discharge instructions were 'vague', then it may not have been explicit enough to trump what's on the bottle. That is, if the instructions just say 'acetaminophen as needed', as opposed to 'x mg of acetaminiphen per day'

I agree, if they explicitly advised a higher dose than the directions, then that would warrant concern.
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Dicast
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Dicast »

Almost all hospitals have an email, phone number or contact for filing complaints with the administration of the hospital. Most of the time this information should be included with your discharge paperwork. It might only be a couple of lines and you can probably find it on the hospital website under complaints/grievance/quality headings. I would start with that point of access. You may find they are more than willing to make up for their mistake and even more so try to prevent it in the future. Your insurance company has much less power and incentive to help you. You would also want to track who you talk with and the responses you get from each individual. If you have to resort to an attorney for lack of response then having all the prior information will be helpful to them.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by CedarWaxWing »

Dicast wrote:Almost all hospitals have an email, phone number or contact for filing complaints with the administration of the hospital. Most of the time this information should be included with your discharge paperwork. It might only be a couple of lines and you can probably find it on the hospital website under complaints/grievance/quality headings. I would start with that point of access. You may find they are more than willing to make up for their mistake and even more so try to prevent it in the future. Your insurance company has much less power and incentive to help you. You would also want to track who you talk with and the responses you get from each individual. If you have to resort to an attorney for lack of response then having all the prior information will be helpful to them.
1+ The hospital may well decide to not balance bill you... unless your instructions were clearly sufficient, but you need to be in communication with billing office, and likely the patient advocate office...

Best,

M
mhalley
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by mhalley »

What was wrong with the instructions exactly? Was it an exact dose, or take acetaminophen as directed? Was he Rx another medication that contained acetaminophen? Most of these instructions are either standardized or computer generated. If the instructions are wrong, then there might be a case, but saying the magic word malpractice should perk everyone up in regards to the bill, but if there was none they might not give any.
traveltoomuch
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by traveltoomuch »

Dicast wrote:Almost all hospitals have an email, phone number or contact for filing complaints with the administration of the hospital. ... I would start with that point of access. You may find they are more than willing to make up for their mistake and even more so try to prevent it in the future.
I would start there, too. Do not expect success, and do not allow them to drag the matter out. Give them one chance and a very firm deadline.

I'd start with them because 1) it will be less painful than engaging a malpractice attorney, and 2) it would help alleviate the guilt I might feel when the malpractice attorney seeks more money than is currently on the line. I could at least tell myself "I offered them a chance to get out of this cheaply".
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doug1022
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by doug1022 »

Thanks everyone for your comments - very helpful.

To be more clear, this was a dr prescription for acetaminophen - not over the counter. And the instructions on the rx bottle exactly matched the instructions on the discharge note. There was nothing on the rx bottle or in the discharge notes to suggest that there was a maximum daily dosage. We followed the dosage instructions to the letter.... until my wife just happened to randomly discuss my son's recovery with a friend (a nurse) who thought the dosage sounded very high. If that conversation had not taken place, we would have continued to medicate our child per the original instructions and the outcome might have been far worse.

I will take all of your suggestions into account and will plan a course of action. Again, thank you!
staythecourse
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by staythecourse »

Do as you feel is right, but can say going to an attorney is not going to be useful. Malpractice attorneys rightfully are looking for $$ at the end of a case. One of the determinants is damages. The only damages is the readmission. Being paid on contigency to get you off from the subsequent bill is not going to motivate a malpractice lawyer. It is not like the movies. Lawyers simply look to see if they can make a good profit on a case since they are taking on ALL the overhead of pursuing the case. That is VERY expensive think 5 to 6 digits.

As mentioned if the amount given to the child was prescribed outisde of what the manufactures recommend you have a case. Now the question remains as mentioned above will anyone take the case. My likely answer would be no. Now if your kid had liver toxicity and subsequent liver cirrhosis necessitating a liver transplant or life long care then absolutely you will have MANY lawyers wanting that case. Good news is your kid is fine so no real damages. I don't see anything that would indicate a good chance at punititive damages either.

Asking the hospital to cut the bill is your best bet. It likely won't get far either as they have no skin in the game. It isn't like there is anything medically liable they are on the hook for so why should they care. The provided the services requested. Nothing more and nothing less. If yiou pay great. If youd don't you just get sent to collections.

Good luck.

p.s. If you are considering a lawsuit I would discuss with the lawyer BEFORE paying any bill associated with subsequent readmission. This may infer to the court your acceptance. Check with a laywer to pay or not to pay or does it make a difference if you want to pursue medical negligence.
Last edited by staythecourse on Wed Aug 17, 2016 4:21 pm, edited 1 time in total.
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letsgobobby
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by letsgobobby »

I'm a physician and have sat on risk management and patient outreach committees.

The successful approach at our hospital would be along the lines of, thank you for the care. I am so glad you saved my son's life because the Tylenol could have killed him. I am willing to not sue you for malpractice if you do not bill me for the services of the second admission. You may need to say it a little nicer but that is the quid pro quo. There may be some details around provider vs facility billing and you will need those details in writing.

Given the amounts involved, it would not surprise me if you need an attorney. But given the facts as you've described them, I think you have a considerable case for not paying.
staythecourse
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by staythecourse »

letsgobobby wrote:I'm a physician and have sat on risk management and patient outreach committees.

The successful approach at our hospital would be along the lines of, thank you for the care. I am so glad you saved my son's life because the Tylenol could have killed him. I am willing to not sue you for malpractice if you do not bill me for the services of the second admission. You may need to say it a little nicer but that is the quid pro quo. There may be some details around provider vs facility billing and you will need those details in writing.

Given the amounts involved, it would not surprise me if you need an attorney. But given the facts as you've described them, I think you have a considerable case for not paying.
That ALL depends if said physician is employed by the hospital. If so then there is a good chance as the physician is an employee of the hospital. If the doc is private it would be surprising for the hospital to waive a charge for just doing their job. Actually, in doing so might make them look guilty if future litigation was pursued. As in, "Well CEO Bob Smih if you don't think your hospital did anything wrong why did you feel compelled to just waive your charges?"

My guess you practice in an academic center and risk management is considering the employeed physician as an extension of the hospital. Private world the private practice doc is on their own. No hospital is going to involve themselves in helping out the doc.

Good luck.
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letsgobobby
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by letsgobobby »

I'm not in academics but that is a good point. Still, the hospital grants privileges to the physicians so they can't wash their hands so easily. Don't take this to be legal advice, obviously. This is simply the most productive approach where I work.
staythecourse
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by staythecourse »

letsgobobby wrote:I'm not in academics but that is a good point. Still, the hospital grants privileges to the physicians so they can't wash their hands so easily. Don't take this to be legal advice, obviously. This is simply the most productive approach where I work.
I agree this is the most productive approach. A lawyer is not going to care about the case unless there is money to be had. The family seems to be fair and just don't think they should be responsible to pay for a claim that is not their doing. Just don't see teh motivation on the hospital side for doing it UNLESS they could be implicated, i.e. doc is one of their employees, the default of "tylenol" order printed on discharge instructions is incorrect, etc... Hospitals don't like to give money away.

I wonder if this would be considered a sentinel event by medicare standards. If so, I believe (maybe completely wrong here), that the hospital would not be eligible to receive payment for services rendered on a sentinnel event.

Good luck.
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David1986
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by David1986 »

First off, I'm sorry that this happened to your son. This is a good reminder to those of us in the medical field to be more specific with max dosage/length of treatment. Usually the problem is people not taking their prescribed medication.

How much did they give your son?

For children (assuming his liver isn't impaired), we typically recommend 15 milligrams per kilo of body weight. The max per individual dose I use for kids is 650mg, some may go higher. Dose the child every 4-6 hours as needed, not exceeding 5 doses in 24 hours.

The toxic dose of tylenol is generally around 100 mg/kg.

If you only did this for 4 days, I doubt you were waking the child up every 4 hours at night also to dose him. Even if you did, I doubt he'd reach a toxic level.

These instructions must have given you a hefty dose.

One more thought. Might be a stretch, but the out patient pharmacy that dispensed the medication may be liable if they didn't include a maximum length of treatment too.

Glad your son is okay. Good luck
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by rcjchicity »

I also agree with letsgobobby. I have worked with Risk Management periodically in my position at the hospital. They frequently note that they want to hear about medical errors long before a lawsuit is dropped in their laps in order to try to come to an outcome agreeable to all parties.
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rcjchicity
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by rcjchicity »

Also if the discharge instructions were generated via an electronic health record, the hospital will want to investigate this incident to see if there is a systemic issue. (I'm an Informatics Pharmacist so I'm involved in investigations like this with Risk Management not infrequently. Sometimes it's a system issue, sometimes user error - for which leadership usually requests the system to "dummy proof" somehow)
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by mouses »

Rupert wrote: An anesthesiologist once knocked my child's tooth out during an ear surgery at a state university-affiliated hospital, which resulted in a hospital stay that had not been anticipated or pre-approved by my insurance company.
What is it with teeth and anesthesiology? I've had two ops in the last year, and each time the admissions stuff included a check of did I have missing teeth. i know they put some sort of breathing apparatus in place, but in such a way as to possibly knock out teeth????
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by hcj »

If the surgeon is not an employee of the hospital, I think ultimately your beef is with the surgeon. Therefore, I would ask that office to give you a credit in an amount equal to the hospital bill.
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Raymond
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Raymond »

mouses wrote:What is it with teeth and anesthesiology? I've had two ops in the last year, and each time the admissions stuff included a check of did I have missing teeth. i know they put some sort of breathing apparatus in place, but in such a way as to possibly knock out teeth????
Tracheal intubation
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strafe
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by strafe »

One other consideration: are you certain the overdose was actually sufficient to warrant admission? I am consulted a few times a year by ER docs that grossly overestimate the severity of the exposure. (For example, the treatment guidelines and the lab sometimes describe results using different units of measure...). Once the ER doc makes the decision to admit, everyone thereafter has to pretty much go with the flow.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by toofache32 »

mouses wrote:
Rupert wrote: An anesthesiologist once knocked my child's tooth out during an ear surgery at a state university-affiliated hospital, which resulted in a hospital stay that had not been anticipated or pre-approved by my insurance company.
What is it with teeth and anesthesiology? I've had two ops in the last year, and each time the admissions stuff included a check of did I have missing teeth. i know they put some sort of breathing apparatus in place, but in such a way as to possibly knock out teeth????
"Some sort of breathing apparatus" is a tube to ventilate the patient. To place this tube into the trachea (and not the esophagus) the anesthesiologist has to visualize the opening to the trachea. The patient is put to sleep with the IV and no longer breathing. Now the anesthesiologist has to work very fast to get the tube in the right spot and start the breathing again. Some people have very large tongues or anterior tracheas which make this exceptionally difficult. Sometimes this involves prying off the teeth with the laryngoscope to lift the tongue out of the way enough to be able to visualize the trachea. Yes, it is better to risk the teeth in those dire situations rather than let the patient die. But you would be amazed at how many people have pre-existing bad/broken or loose teeth that got knocked out but "were fine before that anesthesiologist touched them!"
toofache32
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by toofache32 »

I'm curious to know how vague the acetaminophen instructions were. Can you post the exact writing on the bottle and dosage?
michaelsieg
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by michaelsieg »

I and glad that ultimately all was well.
It seems like 2 separate "safety nets" didn't work. I would be surprised if today's EMRs would allow to print out discharge medications, that would lead to an overdose - the big players such as Epic or Centricity essentially don't allow you to write for a too high Tylenol dose or any other drug for that matter.
The other safety net that appeared to have failed is the pharmacist filling the prescription, I just can't imagine that the (likely weight based) dosing was too high.

It is hard to know if really substandard care was delivered if we don't know what was written on the medication container and on the discharge instructions.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Paul78 »

[/quote]
That ALL depends if said physician is employed by the hospital. If so then there is a good chance as the physician is an employee of the hospital. If the doc is private it would be surprising for the hospital to waive a charge for just doing their job. Actually, in doing so might make them look guilty if future litigation was pursued. As in, "Well CEO Bob Smih if you don't think your hospital did anything wrong why did you feel compelled to just waive your charges?"

My guess you practice in an academic center and risk management is considering the employeed physician as an extension of the hospital. Private world the private practice doc is on their own. No hospital is going to involve themselves in helping out the doc.

Good luck.[/quote]

even if it was a private physician the hospital still has some responsibility. The RN and pharmacist DO work for the hospital. They are both responsible for reviewing orders and finding mistakes (wrong dosage, wrong medication, max dosage, ect). It can be reasonable assumed (ie basic standard of care) that the RN and pharmacist are expected to know the max daily dose of acetaminophen...

Having said that I can not image the was zero literature provided regarding the max dosage. Yes the MD's order probably said tax x tabs every 4 (or 6 or 8) hours as needed for pain with no mention of the max dose. Yes there might not have been a sticker on the bottle (these generally highlight common side effects). But wasn't there page(s) included with the medication describing general usage, side effects, etc. Those page(s) would include the max dosage. If that literature was provide that might cover the hospital.
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Watty
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Watty »

I don't know about all the medical issues but if your insurance has an out of pocket maximum then you may have hit that somewhere in the multiple hospital stays so your share of the expenses might not be as high as you are expecting.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by letsgobobby »

michaelsieg wrote:I would be surprised if today's EMRs would allow to print out discharge medications, that would lead to an overdose - the big players such as Epic or Centricity essentially don't allow you to write for a too high Tylenol dose or any other drug for that matter.
Putting aside prohibited medical facts, as a personal consumer issue this is not true. EPIC will flash an alert that the dose exceeds a maximum recommended dose, but these are frequently bypassed with a single click. In fact there are so many alerts on so many issues that behaviorally providers become inured to them; this is called "alert fatigue." It is no different than any other stimulus to which one can become desensitized - analogous to 20% declines in the stock market, your little girl shouting "boo" every evening from behind the living room sofa, your car's oil pressure gauge flashing red even though you've checked repeatedly and know your oil pressure is fine. More poetically, this is the boy who cried wolf.

So for consumers (patients), no matter how good your doctor or how sophisticated their EMR, it helps to be informed. Mistakes happen and they can be life-threatening. My patients let me know of errors (an extra zero on an rx, a duplicate entry, an incorrect Dragon transcription) with some frequency and I not only welcome it, I encourage my patients to let me know when they find them.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by michaelsieg »

Putting aside prohibited medical facts, as a personal consumer issue this is not true. EPIC will flash an alert that the dose exceeds a maximum recommended dose, but these are frequently bypassed with a single click. In fact there are so many alerts on so many issues that behaviorally providers become inured to them; this is called "alert fatigue."
That is a good point letsgobobby, the "soft stops" and alerts get constantly overwritten, similar to nobody paying any attention to the many false alarms in the ICU everyday.
I really think the whole medical safety research with looking at safety measures as multiple walls of defense against human errors is really still in it's early stages, and hopefully medical errors will be further decreased. But I still think that in this case, 2 safety systems seem to have failed.
Also, in our place, we have a lot of hard stops on drug doses, that we can only overriden by talking to the pharmacist - I have to write for these combination drugs like Percocet and Vicodin a lot, and there is no way I could exceed a safe Tylenol dose by writing for too much Percocet, even if I tried.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by denovo »

doug1022 wrote:Hello,

My 13 year old son had a tonsillectomy a month ago, and the hospital discharge notes furnished by the surgeon & his staff included pain management instructions that resulted in elevated acetaminophen levels, which necessitated a subsequent overnight admission to the hospital (overdose protocol, bloodwork, additional dr visits, etc).

The crux of the issue is that the pain management instructions that were provided to us did not articulate a daily limit that we should avoid exceeding. We medicated our child per the instructions, and as a result, he received too much acetaminophen each day for four days. Once we finally figured this out, we brought him back to the hospital for bloodwork, at which point it was determined that his levels were too high and he needed to be admitted on an OD protocol. The surgeon has admitted that the discharge notes were "too vague."

That said, my son is fine now and will not endure any long-term consequences as a result of this error - thank god.

However, we are just now starting to see the medical bills for these additional OD services which we feel are not financially responsible for. Had the pain management instructions been clear, my son would not have had to be admitted and these services would not have been needed. We have reached out to our insurance company hoping that they would act as the conduit between the Surgeon (who was at fault, and not involved in the OD protocol) and the hospital who provided the services. The insurance company has refused to take a position in this matter.

What are our options? Do we work directly with the surgeon's billing office? Do we simply refuse to pay?

Sorry, we've never been down this road before and are looking for some guidance.

Thanks

Simple. Tell the surgeon/hospital you'll sue them and file a complaint with the medical license board.
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katnok
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by katnok »

I'm also interested in knowing the instructions.
Can you please post the exact instructions and weight of your child on the day of the discharge?
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dodecahedron
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by dodecahedron »

Paul78 wrote:
even if it was a private physician the hospital still has some responsibility. The RN and pharmacist DO work for the hospital. They are both responsible for reviewing orders and finding mistakes (wrong dosage, wrong medication, max dosage, ect). It can be reasonable assumed (ie basic standard of care) that the RN and pharmacist are expected to know the max daily dose of acetaminophen...

Having said that I can not image the was zero literature provided regarding the max dosage. Yes the MD's order probably said tax x tabs every 4 (or 6 or 8) hours as needed for pain with no mention of the max dose. Yes there might not have been a sticker on the bottle (these generally highlight common side effects). But wasn't there page(s) included with the medication describing general usage, side effects, etc. Those page(s) would include the max dosage. If that literature was provide that might cover the hospital.
But hospital pharmacies, in my experience, do not give you the actual medicines to use after discharge, so the hospital pharmacist would not have been involved in dispensing the meds needed after discharge and would not have opportunity to enclose pages of info with the meds.

The hospital nurse gives you your discharge instructions and if those instructions include meds that require a prescription, they give you the prescription. You are on your own buying the meds at the pharmacy of your choice. In fact, when a relative recently had elective surgery, her surgeon gave her the instructions for the meds she should buy ahead of time (even before she went into the hospital for the surgery) from her local pharmacy, so she wouldn't be inconvenienced by the need to stop at a pharmacy on the way home from the hospital afterwards.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Dottie57 »

dodecahedron wrote:
Paul78 wrote:
even if it was a private physician the hospital still has some responsibility. The RN and pharmacist DO work for the hospital. They are both responsible for reviewing orders and finding mistakes (wrong dosage, wrong medication, max dosage, ect). It can be reasonable assumed (ie basic standard of care) that the RN and pharmacist are expected to know the max daily dose of acetaminophen...

Having said that I can not image the was zero literature provided regarding the max dosage. Yes the MD's order probably said tax x tabs every 4 (or 6 or 8) hours as needed for pain with no mention of the max dose. Yes there might not have been a sticker on the bottle (these generally highlight common side effects). But wasn't there page(s) included with the medication describing general usage, side effects, etc. Those page(s) would include the max dosage. If that literature was provide that might cover the hospital.
But hospital pharmacies, in my experience, do not give you the actual medicines to use after discharge, so the hospital pharmacist would not have been involved in dispensing the meds needed after discharge and would not have opportunity to enclose pages of info with the meds.

The hospital nurse gives you your discharge instructions and if those instructions include meds that require a prescription, they give you the prescription. You are on your own buying the meds at the pharmacy of your choice. In fact, when a relative recently had elective surgery, her surgeon gave her the instructions for the meds she should buy ahead of time (even before she went into the hospital for the surgery) from her local pharmacy, so she wouldn't be inconvenienced by the need to stop at a pharmacy on the way home from the hospital afterwards.
I and family have been given discharge prescriptions since the hospital pharmacy is in network.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Da5id »

denovo wrote: Simple. Tell the surgeon/hospital you'll sue them and file a complaint with the medical license board.
I'd get all the facts clear first. Starting too early with a threat to sue really makes it more confrontational than may be warranted before other options are pursued. I know a doctor at one hospital where he says the policy is to fight to the end on any lawsuit that they feel completely lacks merit, basically to prevent future gratuitous suits against them.

If you really have instructions IN WRITING that don't give better limitations then it seems like you have a case for the hospital to pay something. I've been told by doctors to take doses exceeding the OTC limit (e.g. 800 mg Ibuprofen). If they told you to give your son too much acetaminophen seems like they bear at least some of the responsibility...
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by 4nursebee »

As far as getting facts, the OP needs to provide more detail.

Tylenol has warning label about this exact issue.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by letsgobobby »

4nursebee wrote:As far as getting facts, the OP needs to provide more detail.

Tylenol has warning label about this exact issue.
True for OTC. Not sure about an RX.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by toofache32 »

denovo wrote:
doug1022 wrote:Hello,

My 13 year old son had a tonsillectomy a month ago, and the hospital discharge notes furnished by the surgeon & his staff included pain management instructions that resulted in elevated acetaminophen levels, which necessitated a subsequent overnight admission to the hospital (overdose protocol, bloodwork, additional dr visits, etc).

The crux of the issue is that the pain management instructions that were provided to us did not articulate a daily limit that we should avoid exceeding. We medicated our child per the instructions, and as a result, he received too much acetaminophen each day for four days. Once we finally figured this out, we brought him back to the hospital for bloodwork, at which point it was determined that his levels were too high and he needed to be admitted on an OD protocol. The surgeon has admitted that the discharge notes were "too vague."

That said, my son is fine now and will not endure any long-term consequences as a result of this error - thank god.

However, we are just now starting to see the medical bills for these additional OD services which we feel are not financially responsible for. Had the pain management instructions been clear, my son would not have had to be admitted and these services would not have been needed. We have reached out to our insurance company hoping that they would act as the conduit between the Surgeon (who was at fault, and not involved in the OD protocol) and the hospital who provided the services. The insurance company has refused to take a position in this matter.

What are our options? Do we work directly with the surgeon's billing office? Do we simply refuse to pay?

Sorry, we've never been down this road before and are looking for some guidance.

Thanks

Simple. Tell the surgeon/hospital you'll sue them and file a complaint with the medical license board.

Good grief. This is the exact reason I do not treat attorneys nor their families in my office. By definition, they have a much higher tolerance for conflict than me which gives them an unfair advantage.

Contact the administration of the hospital and present them the facts. If this is as obvious as the OP makes it sounds, everything will be remedied easily. But I'm still waiting to hear what the prescription actually said.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by staythecourse »

denovo wrote:Simple. Tell the surgeon/hospital you'll sue them and file a complaint with the medical license board.
Everyone is entitled to their own opinion, but when giving advice to others there should be some logic behind it. First to sue you will need to find an attorney to pick up the case. No offene to the OP, but there are no damages outside of a readmission to seek out for a lawyer so their interest level will be low.

Anyone can report anything to the medical board, but they will likely tell you they focus on ethical violations then any negligence (which is what the legal system is meant for) or billing issues (which is between provider, patient, and insuarnce company). So you can use this avenue, but they have no power nor interest in changing or dropping a bill. Even if you get the state board to censor the physician that does not effect the bill outstanding. And I can bet at that point the physician will not be inclined to work with the patient on helping them out.

As mentioned I would proceed to talk to the doctor's office and/ or hospital direct and see what can be done.

Good luck.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by staythecourse »

denovo wrote:Simple. Tell the surgeon/hospital you'll sue them and file a complaint with the medical license board.
Everyone is entitled to their own opinion, but when giving advice to others there should be some logic behind it. First to sue you will need to find an attorney to pick up the case. No offene to the OP, but there are no damages outside of a readmission to seek out for a lawyer so their interest level will be low.

Anyone can report anything to the medical board, but they will likely tell you they focus on ethical violations then any negligence (which is what the legal system is meant for) or billing issues (which is between provider, patient, and insuarnce company). So you can use this avenue, but they have no power nor interest in changing or dropping a bill. Even if you get the state board to censor the physician that does not effect the bill outstanding. And I can bet at that point the physician will not be inclined to work with the patient on helping them out.

As mentioned I would proceed to talk to the doctor's office and/ or hospital direct and see what can be done.

Good luck.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by spitty »

The hospital is not at fault here and deserves to be paid; they treated a sick patient's complication who was discharged home 100% healthy. The onus here is on your physician who has admitted fault, saying med instructions were too vague. I would approach the billing person/office manager in the Dr's office and explain the situation, stating that you want your out of pocket amount taken care of for this complication. They can then try to work it out with the hospital for you--if the Dr takes tons of patients to this facility, they may write off your balance. If the doc is employed by the hospital they more likely will. Next step would be having your lawyer write a letter to the Dr who will get then get his/her malpractice co. involved. If they balk at paying your OOP expenses, you'll then have to decide if you want to file a lawsuit which can really crank up the $$$! And yes, there may be fault on the part of your pharmacist; they're supposed to be another safety valve against medication errors. Post exactly what they wrote on your med bottle for dosage.
Last edited by spitty on Thu Aug 18, 2016 9:05 am, edited 1 time in total.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by Rupert »

toofache32 wrote:
mouses wrote:
Rupert wrote: An anesthesiologist once knocked my child's tooth out during an ear surgery at a state university-affiliated hospital, which resulted in a hospital stay that had not been anticipated or pre-approved by my insurance company.
What is it with teeth and anesthesiology? I've had two ops in the last year, and each time the admissions stuff included a check of did I have missing teeth. i know they put some sort of breathing apparatus in place, but in such a way as to possibly knock out teeth????
"Some sort of breathing apparatus" is a tube to ventilate the patient. To place this tube into the trachea (and not the esophagus) the anesthesiologist has to visualize the opening to the trachea. The patient is put to sleep with the IV and no longer breathing. Now the anesthesiologist has to work very fast to get the tube in the right spot and start the breathing again. Some people have very large tongues or anterior tracheas which make this exceptionally difficult. Sometimes this involves prying off the teeth with the laryngoscope to lift the tongue out of the way enough to be able to visualize the trachea. Yes, it is better to risk the teeth in those dire situations rather than let the patient die. But you would be amazed at how many people have pre-existing bad/broken or loose teeth that got knocked out but "were fine before that anesthesiologist touched them!"
In my child's case, it did indeed happen during intubation. And it was a baby tooth that was not noticeably loose prior to surgery but could have been looser than a permanent tooth. (She was 4, which is a little early but not abnormally early to lose your first tooth.) The real problem in our case was that no one noticed the missing tooth until I pointed it out to them following a 3-hour surgery. They had no idea where the tooth was so the entire hospital had to go on high alert. The OR had to be searched, etc., before they finally found the tooth in my child's stomach using a bedside Xray. Worst case scenario, of course, was that it was in my child's lung. I was never able to find out for sure, but I suspect an intern or resident was responsible. This was in a teaching hospital. The next morning, the head of anesthesiology came to apologize and, since it was my child's first tooth loss, play tooth fairy. We didn't sue or threaten to sue anyone because the hospital and doctors handled it properly after they were alerted to it and because there was no permanent damage. (I did take my child to a dentist within a few days of it happening to make sure.) Had I been billed for that unexpected hospital stay, my reaction would have been different. I did do a little Google search on the issue. Turns out the number one reason anesthesiologists are sued is for tooth injury during intubation.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by plannerman »

I had a botched surgical procedure that required readmission to the hospital and followup corrective surgery. My guess this that this is not all that unusual an occurrence, and I suspect the surgeon and hospital both have "standard" procedures they follow. You need to push back on the hospital until you are able to figure out what those procedures are. The hospital's procedure might be to bill first to see what happens and then negotiate. My guess is they will eventually waive the bill as a professional courtesy to the surgeon (it may depend on how much business the surgeon generates for the hospital). In my case, neither the surgeon nor the hospital billed me, nor my insurance company for the readmission and followup surgery. The anesthesiologist, however, did bill the insurance company and I ended up with a copay he refused to waive and I eventually paid.

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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by pshonore »

letsgobobby wrote:
4nursebee wrote:As far as getting facts, the OP needs to provide more detail.

Tylenol has warning label about this exact issue.
True for OTC. Not sure about an RX.
Every retail pharmacy in my area (CVS,WalMart,Costco,etc) provides a 2 or 3 page print out detailing dosage, contraindications, side effects, etc for all new Rx and refills. I don't know how many people read them.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by neurosphere »

At minimum, regardless of what you ultimately decide from a legal standpoint, I would send a letter to the hospital explaining what happened, and that you expect the hospital conduct some sort of review of procedures and plan to implement changes so that this does not happen again (if indeed it was a preventable error and a clear case of dangerous instructions, vague or otherwise).
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by White Coat Investor »

Wow! Medical and legal advice in one thread! Surprised it got this far.

I'd contact the hospital risk management folks. They prefer to resolve this sort of stuff without attorneys because attorneys are expensive. It sounds like you just want to be made whole, not get additional "pain and suffering" money.

Are they technically responsible for your bills for a complication? No. We see complications all the time and still send the bills. Is this worth a full court malpractice suit press? No. It's such a small amount of money and the 5 years of time and money to prosecute it isn't worth it. So it really comes down to whether the hospital manager and the surgeon would rather give up a few thousand from your insurance company and you in exchange for not having to do all the legal crap, offer a settlement etc. The main bill is from the hospital, not the surgeon, so I'd start there.

Glad everything worked out medically.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by mouses »

letsgobobby wrote:
4nursebee wrote:As far as getting facts, the OP needs to provide more detail.

Tylenol has warning label about this exact issue.
True for OTC. Not sure about an RX.
If I got printed directions from a medical person, I don't think I'd get out my magnifying glass and read the directions on the container. One would expect the directions to be accurate, and to even override container directions.
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Re: Medical Billing Question - Hospital Discharge Instructions led to acetaminophen OD

Post by mouses »

pshonore wrote:Every retail pharmacy in my area (CVS,WalMart,Costco,etc) provides a 2 or 3 page print out detailing dosage, contraindications, side effects, etc for all new Rx and refills. I don't know how many people read them.
Probably none. It's like reading an insurance policy, even if you read it, you'd have no idea what it meant.

RiteAid supposedly has a way to tell them, please don't print out these six pages of stuff every time I get my monthly refill, but in practice it does not seem to stop the blizzard of wasted paper.
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