Imagine opening a medical bill and discovering you’ve been charged thousands of dollars for care you never received. Or realizing that the routine 15-minute visit you had in a local clinic was billed as a high-severity emergency. For millions of American patients, this isn’t a hypothetical nightmare. It is often standard operating procedure for the modern corporate hospital system.
Having practiced medicine, I know the true costs of delivering high-quality care, including the overhead, staffing, and supplies required to keep a clinic running. Let me be clear: The astronomical bills patients face today are entirely disconnected from those realities. What we are witnessing is a billing system designed not to reflect the cost of care, but to systematically exploit patients.
If you want to understand how brazen this practice has become, look no further than the recent House Ways and Means Committee hearing, where the CEOs of some of the nation’s largest health systems were called to testify. During the hearing, these executives sat before Congress and defended a system that aggressively drives up patient costs. When committee Chairman Jason Smith (R-MO) asked the hospital CEOs to raise their hands if they would support legislation to equalize payments so patients could afford their care, not a single hand went up.
They defended a status quo where a hospital system can buy a local, independent doctor’s office, change nothing about the care provided, and immediately begin slapping massive “facility fees” on every bill. As the committee highlighted, hospital consolidation over the past two decades has led to a landscape in which just one or two corporate systems control access to care in half of U.S. metropolitan regions. The result? Higher prices for patients and lower wages for workers.
But facility fees are just the tip of the iceberg. The scope of the problem is staggering: Today, an estimated 10% to 15% of all healthcare claims are abusive. While hospital lobbying groups love to frame these discrepancies as innocent administrative errors or the byproducts of a complex billing system, the reality is far more nefarious. This is not always sloppy bookkeeping. This is intentional marking up. Health systems are purposefully gaming medical coding rules to maximize revenue at the direct expense of American families.
One of the most widespread and egregious tactics is “upcoding,” the practice of coding a patient’s diagnosis or visit as far more severe than it was to trigger a much higher insurance payout. Today, emergency department upcoding is a massive issue nationwide. When you look at the billing data, most emergency visits are now coded as Category 3, 4, or 5 CPT codes, the absolute highest severity levels. A patient coming in for minor stitches, a sprained ankle, or a simple, nonthreatening evaluation is often billed as a complex, high-risk emergency. The care hasn’t suddenly become vastly more complicated. The billing departments have just become far more aggressive in extracting maximum profit.
When hospital billing departments systematically upcode and inflate claims, insurance companies face massive, unexpected spikes in total payout costs across their entire network. These inflated bills are passed on directly to businesses and families through steeply hiked monthly premiums and higher out-of-pocket deductibles.
For decades, many of these hospitals asked for tax-exempt status, promising a community benefit in return. Instead, as the Ways and Means hearing laid bare, they gave us less charity care, massive corporate salaries, and a relentless drive to consolidate and raise prices.
ARE AMERICANS DONE WITH HEALTH INSURANCE?
The sacred relationship in healthcare is between the doctor and the patient, not the billing department and the patient’s bank account. As a physician, I believe it is time we demand better.
Congress must stop accepting the hospital lobby’s hollow excuses. Lawmakers need to crack down aggressively on abusive billing practices, mandate strict auditing to end upcoding, and hold these corporate systems accountable for the financial ruin they are inflicting on American families. Healthcare should be about healing, not about how much profit can be squeezed out of a CPT code.
Dr. Richard Popiel is a physician and healthcare executive with more than 30 years of leadership experience in managed care.