Photographic Evidence That Hospitals Should Maybe Rethink How They Bill Patients

Twice a week for the past three months, Consumerist reader P. has been going to her hospital’s gym for brief, doctor-ordered cardio workouts. Her insurance isn’t footing the bill and each session is only $9.00, so she’s been assuming that the hospital was wisely waiting until her tab reached an amount worth billing before it sent an invoice. Not exactly…

“I thought the mailman had accidentally put the entire block’s power bills into my mailbox,” she tells Consumerist about checking her mail the other day and finding 20 envelopes wrapped in a rubber band.

But all those envelopes were for her, and they were all from the hospital. Twenty separate invoices for $9.00 each.

And this wasn’t an issue of a backlog at the post office or someone at the hospital mail room forgetting to send them out. All letters are first notices, all issued on the same date.

P. says she has no intention of remitting separate payments for each invoice, but she also knows the hospital — or more likely, whatever third-party billing company is handling this mess — will probably be confounded when they receive a check for $180.00 with a payment stub that only asks for nine dollars.

But when the hospital bills like this, it is just begging for a patient to miss one of the bills. We had a chance to see the actual paper invoices and had to count three times to make sure we had the correct count of 20 separate invoices. It’s easily within the realm of believability that a patient could miss one or two of these bills.

A single bill for the full amount — or even monthly bills — would minimize the chance of a missed invoice, which means fewer people being sent to collections for pocket change, which means less money the hospital is spending on billing and collections.

If we’re going to rein in healthcare costs in this country, here is one place to start.


Edit Your Comment

  1. PragmaticGuy says:

    And the problem with trying to keep the post office in business is…….???

  2. Red Cat Linux says:

    I don’t think I’ve ever seen a hospital bill that made any sense.

    They contain a language all their own, indecipherable by mortal man. One hospital didn’t send a bill until almost a year after the charges were incurred. One of them slapped on consulting physicians who were in-network, yet somehow were unknown to the patient. Most of them seem to screw up their insurance codes.

    You need the Rosetta stone to figure them out.

  3. binkleyz says:

    Mail them back one big manila envelope with the 20 envelopes inside.

    Write 20 checks, since they are stuck with paying processing fees.

    Hope that someone inside the billing firm sees how silly this is and changes the policy.

    • Kabusted says:

      Seriously, provide 20 checks for 20 bills, but send it in one envelope. Just because they want to support the post office doesn’t mean that you have to. Hopefully they have a postage paid envelope, and if that’s the case, then yes, send them 20 envelopes with 20 payments. They pay both ways.

      • sonotamused says:

        The upside with this method is that you can link each check with a invoice, so that they can not claim that you did pay one of these (because they are just as likely to get the $180 check and try to apply it to a payment they have in process instead of an outstanding bill – I have had that happen to me).

        The downside to this? Some banks have a limit to the number of checks you can write against a bank account per month (depending how the account is set up, OP woudl have to check)

        • JJFIII says:

          Another downside would be taking the time to write out 20 checks versus ONE.

        • bbb111 says:

          “…you can link each check with a invoice, …”

          do this literally – staple each check to the corresponding payment stub and then staple the whole stack together on the opposite corner.

          Of course, this is just to make sure they don’t miss one.

          Actually, I’ve heard of many cases where multiple checks were in one envelope and only one was cashed – the processor pulls out some of the contents and throws out the envelope.

      • nauip says:

        Probably you’d just give some low wage AR clerk a little extra work and the entire event would go unnoticed. This is probably the same AR clerk who knows how dumb the situation is, but isn’t high enough up on the totem pole to help make a difference.

    • Loias supports harsher punishments against corporations says:

      What processing fees do you pay on checks?

      • Not Given says:

        Have you looked at the price of check printing lately?

        • Difdi says:

          As long as a check has all the the necessary things written on it, it doesn’t matter if you scribbled it on a cocktail napkin in crayon.

          So you literally could make all of your checks at home.

          • mianne prays her parents outlive the TSA says:

            Citation please?

            I’ve heard this myth before. but I’m not accepting a note scribbled on a napkin as a valid means of payment. I will withhold goods or services offered until you presented a pre-printed check, cash, or a credit/deb it card for payment. Likewise I wouldn’t expect my bank, a hospital, or any other business to accept such as payment.

            • Andrew says:

              From what I know, a check is valid so long as it has your account #, Routing #, your signature, the check amount, and the payee. the only downside is that it can easily be tapered with and can result in additional processing fees.

    • TasteyCat says:

      This is what I’d do. How else am I going to use my hundreds of checks anyway? Only people I ever write checks to are the tax men.

    • Sudonum says:

      I own 35 lots in the same subdivision. Every year at property tax time I get 35 separate tax bills. I mail in one check with all the stubs. It’s a business check so it lists the Parcel Numbers on the stub. Been doing this for 3-4 years now with no problems yet.

      • quail20 says:

        That’s the benefit a business check has over a personal one. There usually is a spot for defining multiple things being paid with the one check. Last company checks I had allowed for about 7 separate items.

        With this issue and the high chance of them getting something wrong on their end, I’d send checks for each bill.

  4. dolemite says:

    That’s a lot of postage too. Add in the cost of paper, postage, etc. for 20 envelopes and that’s not an inconsequential amount. Maybe another reason our medical system costs are so high. I don’t think I’ve ever heard of a doctor’s office or hospital that has competent billing.

  5. SkokieGuy says:

    One check enclosed with 20 payment stubs in one envelope. It might need an extra stamp because of the weight.

    Or, call the hospital and ask for a statement that will be a single page document with everything you owe and a total due.

    There’s really no problem here.

    • Kimaroo - 100% Pure Natural Kitteh says:

      The problem here is waste and shady billing practices.

      • hexx says:

        There’s nothing shady about this. It is wasteful though.

        • Kimaroo - 100% Pure Natural Kitteh says:

          The shady part is that they send bills like this hoping that you’ll miss one.

          In my situation, I don’t have insurance, but I pay at the time of service in full. About a month later I usually get a bill in the mail for a seemingly random amount from the billing company and that invoice was generated the same day as my appointment. There is no reason for me to be getting a bill, but in order to make sure that this doesn’t go to collections or show up negatively on my credit report, I have to spend multiple hours on hold trying to get the billing company and the doctors office to verify that yes, I did, in fact pay in full and no I don’t owe anything more. It’s an on-going saga, and the billing department seems to do it on purpose. It usually takes me multiple months to sort out because they tell me to wait and see if I receive another bill the following month before I call back to confirm that it was removed from my account.

          Sending out multiple complicated invoices for something that should be entirely simple, in my mind, is a shady business practice. Especially when they have the power to send you to collections over it.

          • AtlantaCPA says:

            I think you’re right, and it’s an attitude of “We have all the power in this arrangement so we have no incentive to look out for the customer.” I’ve had my share of billing arguments too (eg; I send in payment with my account number written on the check and they apply it to the wrong account and try to say it’s my fault). In the end you just feel walked all over even if you somehow come out only paying what you owed.

            • Difdi says:

              If your bank returns an image of the check to you, you can prove you wrote the number and the paper trail proves they cashed it.

              What can they do? Try to collect twice? They get sued and lose. Sue you? They lose.

              • AtlantaCPA says:

                In the example I’m talking about, yes, they tried to collect twice. They were close to sending me to collections which would have seriously dinged my credit. Had I sued them, I’m sure eventually I would have won and gotten them to fix my credit but in the meantime you have sucky credit and that can cost you more money that you’d have to sue again to recover.

                I was able to provide a check image which helped them to fix it, but the real issue is that I sent a check in with the correct payment info, they misapplied it, then they tried to send me to collections. It was only b/c I was extra careful that I found out it was still ‘unpaid’ in their system. The other issue of course is I shouldn’t have to spend hours trying to get them to fix their mistake. Hence my comment about how they have all the power. Sucks.

    • MarkFL says:

      I’d suggest bringing the bills and payment in person. But bringing in that big a stack might lead to the patient being billed for another workout.

  6. Invader Zim says:

    Humor! Where you least expect it…with postage.

  7. El Tedweiser says:

    Throughout my wifes pregnancy we recieved bills between $4 and $45 for various tests. I would say it was minimum 30 seperate bills. Couldn’t they have just sent us monthly statements?

  8. hexx says:

    I don’t understand why she would have assumed the hospital would only send one large bill? Has she never been to a doctor or hospital before? They charge separately for every single visit — each trip to the gym is a new visit.

    If she sends them one check that covers every bill then she is just asking for trouble. The hospital will not see it as one check for 9 bills. They will see it as payment for 1 bill, with the remainder crediting to her account. However she will still be required to pay those other 8 bills or else the hospital will send her to collections.

    What she should do is go to the hospital and, in person, talk to the billing department about paying it all at once.

    • sonotamused says:

      “All letters are first notices, all issued on the same date.”

      It would make sense to get separate bills if they were processed completely individuality. But if she was making visits over a period of time and yet they batch processed them, then it is just a sign of either an outdated billing system or willingless to confuse someone to generate this type of bill (the same amount, for the same type of visit, all with the same date of issue). You would have to read it very carefully not to assume that it was just a massive paperwork error and they were rebilling you for the same visit.

    • MarkFL says:

      It would still be cheaper to send all the invoices in one envelope. Not a big difference, but OP is surely not the only person to experience this.

    • shovelDriver says:

      Doesn’t anyone ever write Invoice #’s on the check’s remarks line?

  9. SamanthaSSJ says:

    Insurance isn’t covering it, so she is paying $9 a visit, twice a week. $180 for 3 months – $60 per month. About twice what membership in a full service gym would cost and I doubt the hospital workouts are any different. Maybe that’s where we should start curbing health care costs – not using hospitals for things we can get elsewhere.

    • MMD says:

      I would assume that these workouts are being monitored (heart rate/stress test?). You can’t do that at the gym.

      • chatterboxwriter says:

        My father just had a stress test — it was $6,000. I think she’d be paying a lot more than $9 if a stress test was involved.

    • GOInsanity says:

      Please tell me where these gyms are. The YMCA is $70/month with our work discount.

      • cnevares says:

        I pay about $31/month with no discount at my local Gold’s Gym in Austin, TX.

      • quail20 says:

        There are gyms in our area that go for $20 a month. Yes, the “Y” is a big rip off if you’re not using the pool, a pool that gets closed for hours every day because some kid puked.

    • Kestris says:

      $75/mo per family at the local rec center here. Of course, if I lived in the county instead of the city, it’ll be $66/mo per family.

  10. BoC says:

    Navin R. Johnson sympathizes…

  11. Hagetaka says:

    Medical coding is such an arcane art that it has become its own growth industry. Seriously- my mother did it for 30 years, and now my sister is training in it. It’s ridiculously easy to make a mistake with major implications for a patient, and since insurance companies tend to deny any claims that aren’t cut and dried first (and plenty that are cut and dried) then pay on appeal, it’s usually the patient that gets the shaft.

    Part of it is understandable, due to the complicated nature of medicine, but much of it is bureaucracy for its own sake. The healthcare industry is a self-perpetuating paperwork machine.

  12. Torchwood says:

    What would really help is if the hospital actually posted their rates on their website. Yes, I know that discounts are negotiated by the insurance companies and that’s fine. Yet, the hospitals are resistant to that. Why? I don’t know.

  13. VicMatson says:

    I have always wondered if these 3rd party billers had some king of agreement with collection companies. Bill for 3rd party dollars!

  14. Not Given says:

    No, you write $9 in the amount of each payment coupon and write a check for the full amount. A lot of places you could also go online and pay it, whether they insisted on separate transactions or not

  15. NeverLetMeDown2 says:

    Hospital presumably has a system that spits out a bill after every visit (which fundamentally makes sense), and they do the actual print/mail in batches (which also makes sense).

    Neither of these processes/policies are in any way unreasonable, it’s just that this is a very odd case where they happen to look ridiculous.

    • Carlee says:

      Even if they mail out invoices in batches, I’m surprised they don’t batch at the end of the month or something like 30-day increments. The hospital only sends out bills once every 90 days? Wouldn’t that mean they’re constantly waiting to get paid?

  16. lovemypets00 - You'll need to forgive me, my social filter has cracked. says:

    I can see both sides of this. Yes, it’s annoying to get 20 different bills, and maybe the hospital could find a way to consolidate. But on the other hand, if you order 20 different things from a supplier, and they’re shipped separately, you’re most likely going to get 20 different invoices sent to you separately, especially if the product is from a separate product line under the big corporate umbrella.

    Look on the bright side! At least they didn’t take the debits out of her checking account 200 times!

  17. Costner says:

    Everything I learned to hate about hospital billing practices occurred when I became a father. Daughter born in December…. by November of the next year I was STILL getting bills in the mail and I had no idea why.

    I had insurance which paid for the bulk of it, and I paid any invoice that came in showing a balance after insurance payments, but between invoices telling me they submitted it to insurance, to invoices telling me what my portion is, to reminders that insurance is still pending, to notices that my insurance from the previous year applied rather than my current year insurance (same company, but different policies since it changed slightly at the turn of the year), to invoices from the doctor, the hospital, the clinic for the follow-ups, pharmacy, random medical equipment invoices…. it went on and on.

    In the end even though I was supposed to pay around $3k or so on top of what insurance paid, I ended up paying much less. It wasn’t that I was avoiding anything, but I just kept waiting for the final bill… and it never came. After a year of random statements that never seemed to give me a final total that I actually had to pay, things just sort of ended.

    I like to think I’m a smart guy, but for the life of me I’ll never understand medical billing. It is pure insanity.

  18. bben says:

    I recently received a bill for $20 Nine months after the hospital visit. Along with the bill was a notice that the appeal period had expired and I would not be allowed to appeal. On investigating. The bill was for the co pay that I luckily paid with a debit card and still had the receipt for. It still took 4 phone calls and well over an hour of my time to get it straightened out. By my estimate, not collecting that $20 that I didn’t even owe cost the hospital billing department far more than they would have gotten just in salary for the employees. And likely quite a bit more in paperwork costs.

    My guess is this was handled by a computer that is too stupid to factor in the cost of collecting that $20 to see if it would be cheaper to just drop the charges. The medical industry could probably save quite a bit of money by just doing a simple cost benefit analysis. If it costs $21 to collect $20 your Net (before tax etc) is negative already. If the victim fights the bill, the cost just went through the roof. And all you stand to gain is $20 to offset the expenses that could now easily exceed $1k. Just write it off as a cost of doing business expense and you may gain that $1 back on taxes.

    • NeverLetMeDown2 says:

      “My guess is this was handled by a computer that is too stupid to factor in the cost of collecting that $20 to see if it would be cheaper to just drop the charges. The medical industry could probably save quite a bit of money by just doing a simple cost benefit analysis. If it costs $21 to collect $20 your Net (before tax etc) is negative already. If the victim fights the bill, the cost just went through the roof. And all you stand to gain is $20 to offset the expenses that could now easily exceed $1k. Just write it off as a cost of doing business expense and you may gain that $1 back on taxes.”

      Until people discover that you’re doing this, and everybody underpays their hospital bills by $20. Collecting might be locally suboptimal, but generally optimal.

  19. internet00jen says:

    An incredible information revolution needs to take place in health care.

    For example:
    I scan medical records from Hospital X to be uploaded into Hospital Y’s “Online Record of Clinical Activity” (digital medical records). Often these medical records will say “printed from servers of Hospital X”. Every time I ask why couldn’t this have been digitally exchanged somehow?


    Diagnostic machines for pace makers print out their readings onto thermal receipt paper (Medtronic, St Judes, etc). I tape these undersized print outs to 8 1/2 x 11 inch paper to be digitized — these things that were printed by a machine — these print outs that existed as information written in 1’s and 0’s — I understand a print out is useful for the doctor for then and there. BUT for the patients official medical records why cant these results be ported into their digital file? And if those thermal print outs ever reach my desk again I can shred them, instead of tape them down to sheets of paper.


    There is a program made by Cerner that deletes a list you’ve been using the program to compile when you hit the key combo “Ctrl+A” — THEY ENGINEERED CTRL+A TO DELETE ALL. It is a feature not a bug. The kicker is: You have to select each item on the list you compiled to print your reports.

    • quail20 says:

      Sounds like a program designed by a non computer user.

    • mharris127 says:

      Such a system exists in Muskegon-Muskegon Heights-Fruitport, MI. Any lab work, X-rays, MRI, CT, whatever is on a system that any doctor located in that area can access. When I had to switch pain clinics all I had to do was sign a HIPAA release at the new clinic and they were able to access my whole medical file. As I live out of area information sent by my local Internist is also scanned into the system once the Muskegon area clinic receives it. My Internist also participates in the local electronic system here and whenever I need ER treatment locally they can also access the information from his office (although the pain clinic information on the Muskegon system is not all on it as the pain clinic sends a summary report rather than the actual files). If these systems could be combined it would be nice but what we have is better than the old pen to paper system of a few years ago.

  20. who? says:

    I was getting physical therapy three times a week for several months, and after the insurance paid, my portion was $9.90 per visit. The hospital sent me 3 bills a week, like clockwork. I managed to get sent to collections over $9.90, because I lost count at one point.

  21. amylynn1022 says:

    Stupid question–why the beep are they _billing_ for a $9 gym visit, rather than taking payment at point of delivery? As far as I am concerned they are seriously mismanaged if they can’t figure that one out.

    That said, I once tried to pay for a doctor’s visit at the office. I had insurance but it was really crappy catastrophic insurance that I knew wouldn’t pay for an office visit and strep test. You’d have thought that I asked the receptionist to go into the waiting room and dance the macarena. She just couldn’t figure out how to calculate my bill and take a check from me. Meanwhile the doctor’s office spend the next six months trading statements with the insurance company, occasionally including me in the exchange. As I predicted, the insurance company paid nothing and the doctor got paid six months later that he would have if he’d just let me paid the day I visited him. Plus he was out the cost of the staff, supplies and postage for his correspondence with the insurance company.

  22. cement406 says:

    I’m surprised that the Post Office actually managed to deliver all 20 of those invoices. The Post Office here randomly returns mail sent to us as undeliverable, but our name and address are correct.

  23. itsjustjane says:

    I work in medical billing and this sounds all too familiar. This doesn’t happen to our self-pay patients, but definitely to our patients with insurance who we provide services for at least twice a week. We’ll get one big check from their insurance and it will cover multiple visits for one patient. So a balance will remain for their deductible and/or co-pay and the bills automatically get generated. I definitely do understand a patient’s confusion when they call and say they have a stack of bills with the same statement date and due date. But I always tell them (only speaking for my work) they can stagger their payments since they got everything in one shot. Also anytime someone has called about making a bulk payment, I always let them know that they can and we will spread it across their visits. If they make the payment over the phone instead of mailing it, I let our cash poster know which visits it should cover. Finally, I wish we could consolidate bills for patients, but our billing software simply does not offer any way to do that.

  24. eezy-peezy says:

    last time I had a medical bill I signed up to pay online.

  25. impatientgirl says:

    I’d write separate checks for all so the billing isn’t screwed up.