Community Grievance Decision Digest
COST OF CARE, RIGHT TO BE INFORMED OF
THE LAW:
Each
patient shall... “1. Have the right to be informed
in writing, before, upon or at a reasonable time after admission, of any liability
that the patient or any of the patient's
relatives may have for the cost
of the patient's care and
treatment and of the right to receive information about charges for
care and treatment services.
2. If
the patient is a minor, if the parents
may be liable for the cost of the patient's care and treatment and
if the patient's parents can be located with reasonable effort, the
treatment facility or community
mental health program shall notify
the patient's parents of any
liability that the parents may have for the cost of the patient's care and
treatment and their right to receive information under subd. 3, except
that a minor patient's parents may not be notified under this subdivision
if the minor patient is receiving care under s. 51.47 without the consent
of the minor's parent or guardian.
3.
A patient, a patient's relative
who may be liable for the cost
of the patient's care and treatment or a patient's guardian may
request information about charges
for care and treatment services at the treatment facility or
community mental health program. If a treatment facility or
community
mental health program
receives such a request, the treatment facility or
community
mental health program
shall promptly provide to the individual making the request written
information about the treatment facility's charges for care and treatment
services. Unless the request
is made by the patient, the guardian of a patient adjudged incompetent
under ch. 880, the parent or guardian of a minor who has access to the
minor's treatment records under s. 51.(30)(5)(b)1 or a person designated
by the patient's informed written consent under s. 51.30(4)(a) as a person
to whom information may be disclosed, information released under this
subdivision is limited to general information about the treatment facility's charges
for care and treatment services and may not include information which
may not be disclosed under s. 51.30.”
§ 51.61(1)(w), Wis. Stats.
[Emphasis added.]
“Before,
upon or at a reasonable time after admission, a patient shall be informed
in writing, as required by s. 51.61(1)(w), Stats., of any
liability that the patient or any of the patient’s relatives may
have for the cost of the patient’s care and treatment and of the right
to receive information about charges for care and treatment services.”
HFS 94.04(2), Wis. Admin. Code [Emphasis added.]
[NOTE:
Subsection 51.61(1)(w) was added to the statute in 1995
and HFS 94 was amended in 1996 to reflect the right to be informed of
costs of care.]
DECISIONS
1.
An
individual was convicted of his 5th Operating While Intoxicated
(OWI) got involved in Rational Recovery, a non-traditional treatment
alternative. He then demanded
reimbursement for all costs of his prior treatments for the OWIs.
He was properly informed of
the costs of his care at the time of admission to those treatment
programs, so he was not entitled to
any refund of costs he already paid. . (Level III decision in Case No.
98-SGE-02 on 10/13/98, upheld at Level IV.)
2.
A
county human services department (HSD) did
not have a policy in place for contacting
clients who are emergency detained.
Having such a policy is not
mandated by law, but is a good
risk-management practice. Had
the HSD had such a policy, they would have found out that this particular client had insurance that would have covered her stay in another facility, where her treating
physician also happened to work. This resulted in her staying at the
original place of detention longer than necessary and costing her money
from her own pocket. It violated her right to the least restrictive setting.
Also, the client should not
be held personally responsible for the increased
cost of care. (Level IV decision in Case No. 99-SGE-03 on 11/3/99,
reversing the Level III decision.)
3.
A
patient complained that the facility did
not properly inform her of the increase
in the charges for her cost of care.
The Level II grievance decision found that she was not properly informed of the increased costs and her billing
was adjusted to reduce the fees to the original costs.
This was a fair resolution
of the grievance. (Level III
decision in Case No. 00-SGE-02 on 4/6/00.)
4.
A
patient’s ex-husband attempted to
file a grievance on his ex-wife’s behalf about the fees
charged for her mental health services.
He had been ordered by the divorce court to pay that bill.
He lacked standing to
bring the complaint or appeal it through the grievance process without his
ex-wife’s consent. Patient
rights attached to her, not her ex-husband, since she was the one
receiving the treatment. (Level
III decision in Case No. 00-SGE-06 on 4/14/00.)
5.
An
ex-patient complained about a lack
of billing information about the cost of his stay at a psychiatric
hospital. At the time of
admission to the hospital, the patient and his wife spoke with staff in
the Business Office about the cost of care.
The couple expressed concerns that their
insurance would only cover psychiatric care for a limited time.
They requested to be
informed by the Business Office when
he had reached the limit the insurance would pay, and the hospital
assured them that they would do so. Later,
during his stay, a facility representative informed
the patient that he was close to exhausting his insurance benefits.
At that time, he signed a form called the "Beneficiary
Notification of Noncovered Care: Disclosure and Acknowledgement statement
of Noncovered Services." The
signed form acknowledged that he wished to stay at the hospital to receive
services and that he was solely liable for payment of the services that
would not be covered by his insurance benefits.
The law states that, “A patient,
a patient's relative who may be liable for the cost of the patient's
care and treatment or a patient's guardian may request information
about charges... (emphasis added). The
patient was given written notice of the cost of his care.
However, his wife also
requested information about charges for care and treatment services.
The hospital policy with competent adults is to only inform the
patient receiving services about the cost of the care.
However, his wife was also eligible to receive the same information
because she was his relative, was
also liable for the cost of care, and
had requested that information. It
is very reasonable for the spouse to request be kept informed about the
cost of care for which she is also liable.
Furthermore, since the patient was receiving psychiatric services
at that time, it would also be reasonable for the spouse to monitor the
insurance and billing aspects of care so that the patient could focus more
on the psychiatric treatment that he was there to receive.
Since the wife was not informed nor presented with a release form, she did not
become aware of the bill until it had already exceeded the insurance limit
and the patient had been discharged. Thus
the patient’s right to be
informed of costs of his care was inadvertently violated by the
hospital. At the time of
admission, the hospital should have presented him with a Release of
Confidential Information to release his specific billing information to
his wife. Without
the signed consent, his wife
would only be eligible to receive general
billing information that is not specific to the patient, such as the
daily cost of inpatient care and any policies about how costs for care are
billed at the hospital. (Level III Decision in Case No. 03-SGE-07 on
4/22/04.)
6.
A
psychiatric hospital erred by not also informing the patient’s wife when his cost of care
exceeded his insurance coverage, as she requested.
The hospital needed to
revise its admissions policies and procedures to cover
release of billing information to those who may be responsible for it.
The couple requested that the remainder of their outstanding bill
for psychiatric care be waived. While
it is concluded that his rights were violated, the remedial
action requested exceeds the scope of the grievance process.
If the couple wants to pursue that resolution independently, they
would need to contact the facility to request a settlement or a private
attorney for civil litigation. (Level III Decision in Case No. 03-SGE-07
on 4/22/04.)
Last Updated: November 07, 2006 |
