DEALING WITH YOUR UNPAID PROFESSIONAL BILLS

By Dr. Lalit Kapoor ©

The issue of patients not paying professional charges of doctors and hospitals keeps sticking out like a sore thumb every now and then. Durable solutions for the same seem to be elusive but anecdotal events keep provoking knee-jerk responses, bordering between the unreasonable and bizarre.  The issue came to a boil a couple of years ago. Check out the story.

CASE 1

A seriously injured patient, a case of head injury following a metallic object exploding at the factory where he worked, underwent life-saving neurosurgery at a large hospital in Mumbai. He had a fairly good recovery and was fit to be discharged a month later. However, he refused to pay the balance amount of hospital bills amounting to Rs. 1, 93,000/-

Instead, he disputed the bill, saying it was excessive, and he had a long list of allegations of negligence against the hospital, doctors, nursing staff, and physiotherapists and so on. He said he wanted to be shifted to another hospital. The hospital agreed to discharge him but only after clearing the pending bills.

The response of the patient to this was to file a Habeas Corpus Writ Petition in the Bombay High Court citing wrongful confinement by the hospital and sought Orders of the court for the discharge of the patient without clearing his dues and for registering a Criminal Complaint against the hospital and its staff for illegal detention.

Upon this the Court ordered discharge of the patient and said “you cannot confine a patient over an unpaid bill”. The Division bench of the High Court , however, acceded that “hospitals are entitled to receive their legitimate bills” and said it was “…concerned about the larger issue raised “ and “what kind of guidelines can be laid down”. 

Accordingly, it converted the petition into a PIL and allowed stakeholders like Association of Medical Consultants, Association of Hospitals, and so on to apply for intervention. Incidentally, this case is still ongoing and final directions of the court are awaited. Advocate Rui Rodriguez is representing  AMC ably.

First of all, we need to determine the extent and enormity of the problem. Is the problem exaggerated or is it more prevalent than is imagined?

The fact of the matter is that patients refusing to pay hospital bills is not uncommon and I have come across a lot many such situations. It was my impression that corporate and professionally managed large hospitals are immune from this problem. But I revised my impression following discussion with Admin officers of a few top corporate hospitals.

I was told they have a fair amount of bad debts and are unable to recover them. Especially with long stays in ICU when the bills mount to substantial levels, they are pressurized by politicians, government officials, and so on, to waive the bills.

CASE 2

Very recently, a colleague who runs a mid-size hospital in the suburbs told me of a female patient whom they operated for adenocarcinoma colon with local spread and with a number of co-morbidities. At the time of discharge, when the relatives were presented with the final bill, the total bill being about Rs 4 lakhs, the relatives promised to pay the amount and take the patient home. However, they disappeared for the next 10 days, stopped visiting the patient, and refused to respond to phone calls and messages. Meanwhile, the patient though fit to be discharged, kept occupying a deluxe room bed and enjoying all the facilities of the hospital including food, medicines, etc. Eventually, the hospital decided to inform the police who somehow located the relatives who then came to the hospital but with some political leaders in tow. The hospital was coerced into accepting only fifty percent of the pending amount with a promise to pay the balance shortly. This of course never happened and the bills had to be relegated to the ‘Bad debts’ file!!

I do wish judges are made aware of such incidents, which are aplenty, and think twice before calling doctors merciless and mercenary!

SPECIAL GROUP OF WILFUL DEFAULTERS 

There is also this special group of willful defaulters viz. TPAs and insurance Companies who think nothing of delaying or even denying legitimate bills of doctors and hospitals. But that is another story and I will not dwell on it.

Most doctors are too embarrassed to talk about it and would rather forego the unpaid amount. And besides, as it turns out, a doctor talking about money, even if it is rightfully due to him, is considered indecent (Remember ‘noble profession’?)

CASE 3

A Surgeon operated a case of Intestinal Obstruction in a case of Pulmonary Tuberculosis after explaining all the risks and the guarded prognosis. Post-op the patient developed complications and thereafter expired after several days. The relatives expressed their gratitude to the doctors profusely for having done their best to save the patient.

The balance amount of their bill was about Rs 30,000. But the relatives expressed their inability to produce the money immediately and requested that they be permitted to pay the same after a week or so. The hospital reluctantly agreed to the same despite their past experience with such promises.

The relatives, of course, did not return to pay the amount. Instead, 2 weeks later, the doctor received a call from the local police station informing him that the relatives of the patient had lodged a Police complaint of criminal negligence against him and his hospital leading to the death of the patient.

Following this, the doctor got hassled by the intimidating Police procedure and forgot all about recovering his money.

Comment: Good strategy on the part of the relatives for not paying the doctor his legitimate dues! And good use of the dictum—Offence is the best defense!!

This kind of behavior is not at all uncommon.  Of course, there are some variations----this may happen not necessarily after the death of a patient. It could even happen when the patient has recovered perfectly but the bills have mounted. It is a fact that a good proportion of violence against doctors is a strategy to avoid paying the hospital bill.

Alternately, threats of legal action for alleged negligence, threats of adverse media publicity are used –all with the ulterior motive of not paying your bill.

Coming back to the Court case mentioned above, it is worth considering some excerpts from the Order of the judges. 

📌“Learned Government Pleader appearing for the State has submitted that the hospitals do not have any right whatsoever to illegally detain the patient for non-payment of their dues. It amounts to a criminal offense which is punishable under the IPC”

📌“We are of the view that though hospitals have a right to recover the amount which is due and payable by the patient, they cannot resort to the detention of the patient on that pretext. At the same time, some mechanism has to be evolved in order to recover the rightful dues of the hospitals.”

 📌The real problem is that there is no transparency in bills.

📌There are cases where relatives of a patient are not even allowed to take away the dead body of the patient without paying the bills

COMMENTS

1. It is conceded that forcefully confining a patient for unpaid bills or refusing to hand over a dead body to the relatives for the same reason is not a solution and should never be done.

2. Professional charges of doctors and hospital tariffs can never be uniform or standardized and are bound to vary depending on expertise, infrastructure, quality of services provided, and so on. This is the case all over the world and stands to reason.

3. However, transparency of charges is undoubtedly essential. Wherever possible, especially in non-emergency cases, the cost of treatment must be ‘standardized’ for a particular individual set-up and should be conveyed to patients in an upfront manner so as to inspire confidence and credibility. Thus the patient can make an informed choice of a health care provider. In this way, market forces are bound to operate. In any case, it is a well-accepted fact that even currently, patients indulge in what is referred to as ‘medical shopping’, which includes bargaining, before taking a decision. One may argue that this is true only of non-emergency cases. But a suitable extension can be made in emergency cases inasmuch as basic charges are concerned which should be accessible to patients and their relatives, preferably in a written format. Patients also need to be explained that there could be several variables in treatment outcomes and costs could vary accordingly.

4. The proposal that charges be prominently displayed in a hospital or nursing home is unacceptable. I think this is extremely demeaning to both patients and the health care providers and is almost akin to charges of food items being displayed in an Udipi restaurant. This is uncalled for as long as a patient can access the charges in a written format, on-demand.

5. On the question of patients being asked to pay an advance deposit on admission, it must be clarified that this is perfectly legitimate.  It would be helpful if the practice of taking an advance deposit is not demonized by Courts and Media. Understandably, in an emergency situation, treatment cannot and should not be withheld for lack of immediate availability of financial resources

The courts need to examine the dilemma that whereas patients should not be detained on account of unpaid bills, health-care providers too need protection to recover their legitimate bills and some type of mechanism must be evolved to recover their rightful dues. However, filing civil claims in courts against every non-paying patient is not the answer to the problem as it is not practical and can become a self-defeating exercise.

PROPHYLAXIS

💊Corporate hospitals have a comparatively lower incidence of non-payment of bills on account of their impersonal and cut-and –dried systems of billing in place. Nursing homes must take a cue from them. For example, asking the patient to make an adequate advance deposit pre-admission after discussing the estimated expenses. There is no law disallowing to do this except in emergency cases.

💊Emergency cases—basic and probable charges can be explained with the possibility of variability  based on outcomes

 💊Preferable to give the patient an estimate in writing duly acknowledged by the patient.

 💊A signed declaration from the person responsible for making the payment that final bills be fully settled before discharge.

💊Tracking bills during treatment and raising bills intermittently

GUIDELINES FOR OPTIONS IN LIEU OF IMMEDIATE CLEARANCE OF BILLS 

💉Credit card payment facility is helpful.

💉Post-dated cheque (s) –incl. EMI type payments with interest component factored in. Of course, litigating against bounced cheques is another full-time job. But, something is better than nothing.

💉Undertaking by the patient /authorized relative on stamp paper or suitable judicial format, non-compliance to which should evoke speedy civil action and also invite deterrent criminal action. The legal eagles can help devise an appropriate document that meets the above requirements. In the ongoing court case, this solution has been suggested to the court and it remains to be seen if it materializes into a law.

   Other suggestions at a collective level:

    🔰Information sharing of patients who are defaulters to be put on an online site which can be accessible by the group of hospitals subscribing to the site. Include photo if required.

    🔰Medical debt recovery agencies – which are legal, legitimate, and ethical who will recover your money for a fee just like the  Collecting agencies –under the Fair Debt Collection Protection Act for recovering medical debts in USA

    🔰Admission to a hospital is a virtual contract between hospital and patient. Hence withholding discharge  report, medical treatment reports, etc until outstanding bills are cleared  should be made legal

   🔰In selected cases, file a civil recovery suit against the patient who does not pay your bills. It is agreed that doing so may not be the best option at an individual level, but Associations should sponsor this exercise to create legal precedents.

Lastly, it will be a good idea to examine similar problems in the USA and the way they handle it. We may get some ideas though they will have to be made India-centric.

Please go to Google and type “Medical Debt collection’ or ‘Unpaid medical bills'. You will get a 360-degree view of the issues involved and the remedies practiced in USA. 

CASE 4

A dear friend, who was an NRI in the USA at that time, sustained a nasal fracture whilst on a visit to Singapore while playing Squash. He was rushed to an ER at the nearest hospital where he was promptly attended to by an ENT surgeon and appropriate treatment was given. However, on discharge, his bill had an item “Consultation fees of Plastic Surgeon Dr. P - $ 150. My friend contested the bill and asked why a Plastic Surgeon had been called and, in any case, he said, he didn’t remember any Plastic surgeon examining him. He refused to pay this amount and walked out of the hospital.

A year later, back in the USA, he applied for a car loan. To his surprise, the loan was rejected and the reason cited was non-payment of $ 150 to the hospital. His ‘medical debt’ had been reported to a credit reporting agency with consequent damage to his credit history. The loan was sanctioned after he sent a cheque to the hospital, thereby clearing his ‘medical debt’!!

✅Unpaid medical bills should automatically be recorded in the credit report of the patient by the credit reporting agency (in India CIBIL) so that credit history/worthiness is damaged. In some countries, the person will not get a new job also.

✅Finally, philosophic solution: Treating as bad debt, waiving the loss and adding it to your costs and thereby treating it as cost of doing business!!

    ACKNOWLEDGEMENT: I wish to gratefully acknowledge the very valuable inputs from Advocate Rui Rodriguez in writing this blog.

 Dr.Lalit Kapoor ©

ABOUT THE AUTHOR

Dr. Lalit Kapoor is a General Surgeon practicing in Mumbai. He is the founder of the Medico-Legal Cell, Association of Medical Consultants, and is a medico-legal expert assisting affected members with medico-legal problems for over four decades. He is also the author of the book Better Safe Than Sorry- Medico-Legal Do's & Don'ts.

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