Private hospital bills

Private hospital bills
By Dr MILTON LUM

When looking at a hospital bill, be aware of the differences between doctors’ professional fees and private hospital charges, amongst other things.

THERE are many patients who seek healthcare in a private hospital. The patients, relatives, and their employers or insurers often have to make sense of the various items in a private hospital bill. This article provides information to assist in the interpretation of the intricacies of a private hospital bill.
It is vital to always remember that a private hospital bill has two components, i.e. the doctors’ professional fees and the hospital charges. A distinction has to be made between the doctors’ professional fees and the private hospital charges. This is important as the doctor is, not uncommonly, held responsible for the whole hospital bill because the doctor is symbolic of the healthcare system.

Doctors’ professional fees
The doctors’ professional fees include consultation fees, fees for ward visits, and procedure or operation fees. The professional fees are regulated by the Private Healthcare Facilities and Services Act (PHFSA) and its regulations. The fees in the 13th Schedule of the PHFSA Regulations are the maximum permitted.

The same Schedule stipulates that “When two procedures are performed through the same incision, the fee chargeable for the lesser procedure should not exceed 50% of the fee charged for the first procedure. When a repeat procedure is required, consequent to the first procedure, the fee chargeable for the second procedure should not exceed 50% of the first and when a third repeat procedure is required, the fee chargeable for the third procedure should not exceed 25% of the fee charged for the first procedure.”

The provisions in the 13th Schedule are of particular relevance in the event a patient has to have another procedure or operation should there be complications consequent to the initial procedure or operation.

Patients have a right to an itemised bill for the whole course of the treatment at the private hospital at no extra cost.

Complications are always a possibility whenever a procedure or operation is undertaken. No doctor who performs a procedure or operation can guarantee that no complications will arise, however simple the procedure or operation may appear to be.

Doctors’ professional fees may vary in different private hospitals and clinics and even within the same hospital and clinic. This is because the individual circumstances of each patient are different.
There are no fees prescribed for some of the newer procedures or operations in the PHFSA Regulations. In such situations, the patient will be informed of the professional fees involved.

Patients should not feel uncomfortable about asking the attending doctor(s), what the professional fees are, particularly if a procedure or operation has been recommended. The question should also include the professional fees that would be charged in the event a complication arises.
Any reduction of a doctor’s professional fees is a matter between the individual doctor and patient. Many doctors have waived part or all of their professional fees for patients who are financially not well off or who have incurred a bigger than anticipated hospital bill. Doctors do not publicise this fact because it may be construed as advertising, which is not permitted by the Malaysian Medical Council.

Hospital charges
Unlike doctors’ professional fees, the charges of private hospitals are unregulated, for reasons best known to those involved in the formulation of the PHFSA Regulations.

The private hospital charges include accommodation, laboratory, imaging, medication, labour ward, operating theatre, nursing, physiotherapy and other charges.
Accommodation charges vary in different private hospitals depending on whether it is room with more than two beds, double beds, single bed, or a suite. The choice of accommodation lies with the patient. It would be prudent to consider the duration of stay when deciding on accommodation as this may be factored in the charges for other services provided by the private hospital.

Laboratory charges vary in different private hospitals. Some hospitals do all laboratory tests within their premises while others out-source all or some laboratory tests. Some more complex tests are outsourced to laboratories within the country or even abroad.

Imaging investigations refer to x-rays, computerised tomography (CTs), ultrasound scans, magnetic resonance imaging (MRI). The majority of medical conditions require basic imaging investigations. Complex medical conditions, however, require more sophisticated imaging investigations. In short, not every patient requires a CT or MRI.

If complex laboratory tests and imaging are recommended, it would be prudent to ask the attending doctor(s) about its relevance to the patient’s management and the cost. There are some laboratory tests and imaging that may provide useful information but which do not impact on patient management decisions.

The medicines prescribed are either original compounds or generic ones. The former usually costs more than the latter. However, the price differential between them may not be substantial for many medicines. Doctors prefer original medicines in critical situations as its pharmacokinetics and pharmacodynamics are known, unlike many generics.
Pharmacokinetics refers to what the body does to the medicine administered, i.e. the mechanisms of absorption and distribution of the medicine, the rate at which its action begins, and the duration of its effect, the chemical changes to the medicine in the body, as well as the effects and routes of excretion of its metabolites. Pharmacodynamics refers to what the medicine does to the body.
The attending doctor(s) will advise on whether to continue taking medicines already prescribed for the long term. In general, they should continue to be taken, particularly medicines for high blood pressure, diabetes, high cholesterol, thromboembolism etc. One should be able to bring such medicines to the private hospital.
The charges for the labour ward and/or operating theatre include charges for monitoring, equipment, surgical or disposable items, and medical gases used. There is also a charge for the duration of usage of the labour ward and/or operating theatre.

Patients’ rights
The PHFSA stipulates that a private hospital has a legal obligation to make available, upon registration or admission, its policy statement stating its obligations to patients.
The PHFSA Regulations go on to state that patients have a right to be informed of the estimated charges that may be incurred prior to the initiation of care or treatment. The estimate would be based on an average patient with the same provisional diagnosis of the patient would incur. The patient also has a right to be informed of other unanticipated charges for services that are routine, usual and customary.

Patients have the right to be informed of the private hospital’s billing procedures prior to the initiation of care or treatment.
In addition, patients have a right to an itemised bill for the whole course of the treatment at the private hospital at no extra cost.
These legal provisions will enable patients to know what he or she has been charged for. Anyone who does not comply with these legal provisions will, upon conviction, can be fined an amount not exceeding RM10,000 or imprisoned for not more than three months or both.

The PHSFA Regulations also prescribe a patient grievance mechanism. If there is dissatisfaction with any matter in the private hospital, and this includes private hospital bills, a complaint can be submitted orally or in writing to the private hospital’s patient relations officer, doctor(s), nurse(s) or any healthcare professional of the private hospital.

The patient relations officer has to document all complaints and resolve the complaint within three working days. If she or he is unable to do so, the matter has to be referred to the licensee or person in charge of the private hospital, who shall investigate and provide a reply to the complainant within 10 working days.

The report shall include information to the complainant that if she or he considers the reply unsatisfactory, the matter can be referred, in writing, to the Director General of Health.

Exercising one’s rights
It would be prudent for a patient not to abdicate his or her rights but to exercise it from the time of entry to the time of exit from a private hospital.
Whenever admission, a procedure or operation is advised, one should ask the doctor the rationale for the recommendation. Any caring doctor would welcome such inquiries, as it is well documented that well informed patients have higher patient satisfaction rates than those less informed.
If there is any doubt, additional medical opinions can be sought, either at the same private hospital, another private hospital, or a public hospital. Medical opinions may differ as doctors have different approaches to management, depending on their experience, the facilities available at the private hospital, and their understanding of the patients’ preferences.
It is also important to remember that despite the technological advances, there are still uncertainties in the practice of medicine. It is advisable to ask the attending doctor for the reasons when a referral to another doctor is recommended.
Should a patient require hospitalisation, it would be advisable to ask at admission what the estimated hospital bill will be. One should also ask what the charges are for various services, particularly nursing services. The private hospital has a legal obligation to inform patient what is provided for each item that is to be charged and what is not.
One should always be wary of scam-like practices. For example, patients in one private hospital in the Klang Valley are persuaded by the hospital staff to part with their own medicines upon admission. The nurses subsequently serve patients’ their own medicines back to them. The patients are then charged for the so-called service!
The same private hospital has also set the amount that a ward or department charges its patients as a key performance indicator for its nursing sisters. This has led to unhealthy practices, e.g. patients being charged for nursing assistance when they go the toilet or when they press the call bell etc.
It is a patient’s right not to accede to scam-like or unhealthy practices. For example, one does not have to surrender to the staff of a private hospital the existing medicines that one already has, upon admission.

A useful tip is to request the private hospital to provide a daily update of the charges incurred. This will avoid any surprises when the final bill is presented. It will also serve notice that one is a discerning patient. If the amount has increased beyond one’s expectations, it would be prudent to request for an explanation, without delay. This is particularly so when the hospital stay is beyond that which is anticipated. The request can be made by the patient or his or her next of kin.

A word with the attending doctor(s) would be advisable if one is unable or unwilling to meet the rising hospital bill, which may occur because of complications or unanticipated events. In such situations, the attending doctor(s) has an obligation to make all efforts to arrange the transfer the patient to a public or less expensive private hospital.
When a private hospital bill is presented, it would be prudent to scrutinise it and ask for an itemised bill if the amount is more than that expected from the discussions prior to admission.
A discussion with the attending doctor(s) will clarify what investigations, imaging, procedure, or operation were carried out and whether particular items were used or prescribed.
All medicines have recommended retail prices. Whenever there is any doubt or dispute, a check with the local pharmacy will provide useful information on the reasonableness of the hospital’s pricing.
If the hospital charges for medicines are considered excessive, it is a patient’s right to request the attending doctor(s) to write a prescription for purchase of their medicines from a pharmacy.
Similarly, a check with other private laboratories will provide information on the usual charges for the various laboratory tests. Assistance may also be sought from the attending doctor(s) or one’s regular doctor to check on the reasonableness of charges for laboratory tests and imaging investigations.
Allegations about overcharging by private hospitals and their doctor(s) are not uncommon. The reasons for this include miscommunication, misperception, and overcharging.
If there is any indication that there is overcharging or the explanation provided by the private hospital or the attending doctor(s) is unsatisfactory, a report can be made. In the case of the private hospital, the report can be made to the Health Ministry; and in the case of the attending doctor(s), to the Malaysian Medical Council (MMC).
Both the Health Ministry and MMC have statutory authority to take action against the private hospital and doctor(s) respectively.
There have been occasional reports of private hospital staff refusing to release the body of a deceased patient from the mortuary until the hospital bill has been settled in full. Such conduct is considered unethical and any doctor involved in such activity may be the subject of disciplinary action.

Discounts
The question of discounts given by private hospitals to managed care organisations (MCOs), insurance companies, and corporate organisations crops up from time to time. The argument given is that since healthcare is considered a consumer service by some people, discounts could be given for volume, in the same way that discounts are given when bulk purchases of goods are made.
The press statement by the Director General of Health dated April 2, 2010, is of particular relevance. It states: “The Ministry would like to reaffirm that the practice of fee-splitting is a breach of the Private Healthcare Facilities and Services Act 1998 (Act 586) and its regulations. It is also unethical and is considered as a form of serious professional misconduct by the Malaysian Medical Council.
“Fee-splitting is defined under the Regulations of Act 586 as any form of kickbacks or arrangements made between practitioners, healthcare facilities, organisations, or individuals as an inducement to refer or receive a patient to or from another practitioner, healthcare facility, organisation, or individual. The term ‘organisation’ here includes any insurance company or corporate body.”
In short, patients’ interests cannot be traded like common goods sold in the supermarket. The fundamental question is: how much value should be placed on patients’ interests, i.e. how and to what extent discounts will benefit patients? Would the range of healthcare benefits of patients be increased? Would their premiums be adjusted downwards in subsequent year(s)? Is it acceptable for non-healthcare providers, whether they are MCOs, insurance companies or employers, to take a slice of the healthcare ringgit for its human resource and marketing expenditures, and provide dividends for their shareholders?
Be aware
There are two components of a private hospital bill, i.e. doctors’ professional fees and hospital charges. The former is regulated by law; the latter is unregulated.
Patients’ rights are already enshrined in the PHFSA and its regulations. There are specific sections in the PHFSA Regulations regarding private hospital bills and grievance mechanisms. It would be prudent for patients who seek treatment in private hospitals to be cognisant of their rights and to exercise it at all times.
A patient has a right to an itemised bill. There are various techniques that can be used to check on the reasonableness of a private hospital bill. If there is any indication of overcharging or the explanation provided by the private hospital or the attending doctor(s) is unsatisfactory, reports can be made to the Health Ministry and/or Malaysian Medical Council.

Dr Milton Lum is Chairperson of the Commonwealth Medical Trust. This article provides general information only and is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation that the writer is associated with.

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