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Medical Bill with Potentially Illegal Charges Going To Collections


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Went to the ER with a broken shoulder.  Doc spent about 15 minutes with me max, and a little more time talking to another Doctor.  When the bill for the Docotor's service came in, he charged for a surgery that was never done.  The medical records has the Doctor's own words stating a surgery is not necessary.  On top of that, the Doctor charged for roughly 3 hours of time when I wasn't even at the hospital for 3 hours.  I have several witness that saw everything that happened while I was at the hospital and are unable to back anything the bill claims happened.  My medical records don't back the bill claims I owe for.  The hospital also verified no surgery was done and was astounded at how a doctor could charge for a surgery he never did.

 

I have disputed the charges with the company the Docotor is affilitated with, the same company the bills are sent out under.  They're now threatening to send the account to collections if I don't pay the bill.  I have also filled a complaint with the Washington State Health Department, complaint is too new for an initial response.

 

Here's the questions.

 

1.  The Doctor can't charge for a surgery he never did?  Or did the laws recently change in this regard?

 

2.  Charging for three hours of work when not even 1 hour was spent on my case (medical records back this up) is gouging?  This is still illegal right?  Or am I full of it?

 

3.  If 1 and 2 are illegal, what about the collections company and, what I consider at this point, illegal reporting to my credit?  FDCRA violations, especially since I have proof (if I am right about everything being illegal) 1 and 2 are illegal?

 

Thanks for any advice.

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Here's the questions.

 

1.  The Doctor can't charge for a surgery he never did?  Or did the laws recently change in this regard?

 

2.  Charging for three hours of work when not even 1 hour was spent on my case (medical records back this up) is gouging?  This is still illegal right?  Or am I full of it?

 

3.  If 1 and 2 are illegal, what about the collections company and, what I consider at this point, illegal reporting to my credit?  FDCRA violations, especially since I have proof (if I am right about everything being illegal) 1 and 2 are illegal?

 

Thanks for any advice.

 

1.  NO he cannot bill for procedures never performed.  However before jumping on the ILLEGAL band wagon consider that it may simply be a coding error.  Getting one number wrong in a billing code can change the charge dramatically and if he accidentally circled the one of "with surgery" instead of without it changes the whole thing.  NEVER attribute to malevolence what can be explained by stupidity.

 

2.  It is not price gouging and the amount of time billed for is not just actual face to face time spent with you in an exam room.  There is also the time spent consulting other professionals and handling the dictation of medical records.  All in all it probably adds up to 3 hours of time.

 

3.  It is NOT illegal to report a debt.  You do have a debt for medical care what needs to be resolved is the AMOUNT of that debt.

 

Most hospitals have a Patient Representative that helps resolve issues like this.  Contact them.  The other thing to do is speak to the MANAGER of the billing department and not some CSR drone who only knows to go by a script they are given to read.  Between that and the complaint to the state you should be able to get this resolved.

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Thanks for the reply.  All good stuff, but let's complicate things a little.

 

1.  He used the code that means surgery, flat out surgery, nothing else.  Confirmed by my medical insurance company at the time and confirmed by the hospital.  He put "surgery" on the bill, plain and simple.  If he messed up, how many letters does it take for the Excutive Director of the billing company to realize that mistake?  Three and counting so far.

 

2.  The nurses confirmed, and witnesses confirmed and directly heard what the nurses stated, he spent about 15 minutes talking to another doctor and another 15 with me.  That's 30 minutes.  I would expect to be charged for 1 hour's worth of time.  What happened to the other 2 hours I was there and 2 1/2 hours billed?  The doctor was in surgery with someone else, not me.  How can someone bill for three hours when I was documented being there for 2 1/2?  Medcial records confirm the time I checked in and the time of discharge, barely 2 1/2 hours.  I think you can start seeing where the gouging is comming from.

 

At this point, you're saying $1,600 for 15 minutes with me and 15 minutes confering with another doctor isn't even outrageous?  Good luck trying to convince a judge of that.  Consider I have had three surgeries due to the injury, all totalling just over $2,000 for the Docotor's charges before the insurance company's negotiated rate, each surgery being over 6 hours.  The going rate for Doctor's charges in my area is $175, confirmed with the state department of health, local hospitals, doctors offices, specialists, etc..  At $550, the ER doctor is charging for 3.14 hours of time.  Add $1,100 for a surgery that was never done?  Please tell where I am wrong complaining about that kind of billing and refusing to pay.

 

3.  I know it's legal to collect on a debt, a debt I actually owe.  That in of itself is common knowledge.  There hasn't been a legitmate amount I owe presented to me.  If there was, that would have been paid ages ago.

 

Contacting the hospital about this problem might get me somewhere.  I doubt it, I'm not the only one dealing iwth this nonsense with doctors at the same hospital.  I'll find out in the morning.

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Thanks for the reply.  All good stuff, but let's complicate things a little.

 

1.  He used the code that means surgery, flat out surgery, nothing else.  Confirmed by my medical insurance company at the time and confirmed by the hospital.  He put "surgery" on the bill, plain and simple.  If he messed up, how many letters does it take for the Excutive Director of the billing company to realize that mistake?  Three and counting so far.

 

2.  The nurses confirmed, and witnesses confirmed and directly heard what the nurses stated, he spent about 15 minutes talking to another doctor and another 15 with me.  That's 30 minutes.  I would expect to be charged for 1 hour's worth of time.  What happened to the other 2 hours I was there and 2 1/2 hours billed?  The doctor was in surgery with someone else, not me.  How can someone bill for three hours when I was documented being there for 2 1/2?  Medcial records confirm the time I checked in and the time of discharge, barely 2 1/2 hours.  I think you can start seeing where the gouging is comming from.

 

At this point, you're saying $1,600 for 15 minutes with me and 15 minutes confering with another doctor isn't even outrageous?  Good luck trying to convince a judge of that.  Consider I have had three surgeries due to the injury, all totalling just over $2,000 for the Docotor's charges before the insurance company's negotiated rate, each surgery being over 6 hours.  The going rate for Doctor's charges in my area is $175, confirmed with the state department of health, local hospitals, doctors offices, specialists, etc..  At $550, the ER doctor is charging for 3.14 hours of time.  Add $1,100 for a surgery that was never done?  Please tell where I am wrong complaining about that kind of billing and refusing to pay.

 

3.  I know it's legal to collect on a debt, a debt I actually owe.  That in of itself is common knowledge.  There hasn't been a legitmate amount I owe presented to me.  If there was, that would have been paid ages ago.

 

Contacting the hospital about this problem might get me somewhere.  I doubt it, I'm not the only one dealing iwth this nonsense with doctors at the same hospital.  I'll find out in the morning.

 

Actually it sounds less like price gouging to me and more like your medical record has become mixed with another patient's file and they have not straightened it out.  Is it causing problems?  Absolutely but I don't think it is nearly as nefarious as you do.  

 

See where the complaint to the state gets you.  For what it is worth:  my father many years ago had a sleep study done at a local hospital.  They charged a lot more than the reasonable and customary fee.  He refused to pay more than R&C.  When the billing department lady threatened to trash his credit and sue him he told her "PLEASE sue me. In fact I want you to because you know as well as I do this won't hold up in court."  (of course it helped that he was a lawyer) Lo and behold they suddenly fixed the "billing discrepancy" and it was never a problem.  Sometimes you have to point out the obvious to them for the issue to be fixed.

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I'm positive they've mixed me up with another patient, I even suggested that.  Mr "Executive Director" still holds firm I had a surgery and the doctor spent over 3 hours on the phone with another doctor, and in writing of all crazy things.  At that point that's when the gouging came to mind.  My last letter even begged the director to take me to court, instead the chicken ****** wants to send me to collections.

 

A suggestion on the state department of health is to file a compliant with the police department and have them start an investigation for criminal activity since at least my bill has illegal stuff on it, who knows how many other people this guy has over charged.  Might just be worth adding more pressure, not like I am doing anything wrong.  Not like I can go to jail for being willing to pay a reasonable charge for services rendered.

 

Wow, all this nonsense over charging me for stuff that wasn't done.  Such an easy problem to fix.

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I'm positive they've mixed me up with another patient, I even suggested that.  Mr "Executive Director" still holds firm I had a surgery and the doctor spent over 3 hours on the phone with another doctor, and in writing of all crazy things.  At that point that's when the gouging came to mind.  My last letter even begged the director to take me to court, instead the chicken ****** wants to send me to collections.

 

A suggestion on the state department of health is to file a compliant with the police department and have them start an investigation for criminal activity since at least my bill has illegal stuff on it, who knows how many other people this guy has over charged.  Might just be worth adding more pressure, not like I am doing anything wrong.  Not like I can go to jail for being willing to pay a reasonable charge for services rendered.

 

Wow, all this nonsense over charging me for stuff that wasn't done.  Such an easy problem to fix.

 

You can file the complaint with the police for sure what you cannot do is force them to investigate or file charges.

 

If they send it to collections I would file a lawsuit against them for FCRA and FDCPA violations along with deceptive trade practices.  Let them prove in court the surgeon did the surgery.

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Check your state laws regarding Fair Business Practices (or some states call it Unfair Business Practices).  All states are different, so I'm not sure if it would cover medical expenses, but I dont see why not.  If a business charges you more than they are supposed to, or for work never performed, and then refused to correct it, any other business you would be able to sue in small claims court over the fraud or misrepresentation of services.

 

If they send you to collections, not only would I go after the CA for FDCPA and FCRA violations, I would go after the billing company and/or company the doctor works for for the potential state law violations.

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You have 2 choices here:

1) You can pay the bill and then take the hospital to court because at that point, you have a claim. The pro with this is that you are not dealing with a collector and your credit will not be damaged. The con of this is that you are out the money unless you win your claim in court.

2) You can not pay, let them send it to a collector and trash your credit report, and then take them to court for FDCPA, FCRA, and possible fraud. The pro of this is you have the money until a court forces you to pay. The con is your credit is trashed and you are going to deal with a collector.

I would suggest going to the hospital in person and request to speak to the billing manager in person. Do not scream on how they are committing fraud. Just say that you are thankful for the care and you want to pay the bill but you want to pay only for the care your received, that you think the doctor confused you with another patient, and that you would like to get this resolved. Until now, you have been getting angry at them (and I don't blame you) but try to control that anger if possible.

If the above does not work and you decide to follow path 2, I would suggest that you make life as hard on the collector as possible to force their hand into court. When they first call you (or you call them after it hits your CR), demand the 5 day letter. Demand the DV and when they do validate, state that the charges are fraud and that you will not pay them (same as a CD letter). Eventually they will realize that the only way to get you to pay is through court and once they hit the courts, you can hit them with all the violations (however, if a year goes by and you do not get to court and the collector committed FDCPA and FCRA violations, you might want to file for those because they have a time limit).

I wish you luck but I bet if you do an in-person visit with the billing department and you keep calm, you might be able to sort this out without all the drama of court.

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Here's the questions.

 

1.  The Doctor can't charge for a surgery he never did?  Or did the laws recently change in this regard?

 

2.  Charging for three hours of work when not even 1 hour was spent on my case (medical records back this up) is gouging?  This is still illegal right?  Or am I full of it?

 

3.  If 1 and 2 are illegal, what about the collections company and, what I consider at this point, illegal reporting to my credit?  FDCRA violations, especially since I have proof (if I am right about everything being illegal) 1 and 2 are illegal?

 

Thanks for any advice.

1. Submitting claims for services not rendered is never okay and subject to The False Claims Act (FCA), 31 U.S.C. §§ 3729 - 3733.  That said, it may have been a mistake since physicians don't go around upcoding willy nilly.

 

2. No, you are not full of it, just perhaps might benefit from a better understanding. In outpatient setting, it's often the face to face time only that can be billed for (to both commercial, and especially federal payors!). But ER coding for services can be complex and not at all face to face time-based. Often it is acuity based on HPI (history of present illiness), review of systems (ROS), medical decision making complexity, and ordering & reviewing labs, radiology, etc. + conferring with radiologists + possible consult with orthopod on call, other services and RX coordination). Those codes are typically 99281 thru 99285. Perhaps he billed for 99284 or so...?  What was the surgery CPT code you saw there? If you said what it was, tit's possible there is a rational explanation for it.  Also, there is no way for any doctor to, "gouge." Each insurance company (and Medicare, Medicaid) have fixed allowables for each service.  If the allowable is $500 for one service, it doesn't matter what the doctor charges (he can charge $5,000 if he wants!) -He still is only going to get $500.

 

3.  What is your proof of illegal billing? I would suspect that there is an explanation for the billing, but could be wrong. If you provide the CPT codes and amounts billed for, then it would help me to figure it out. You will want to make sure that there is no duplicate billing, or balance-billing to you that is inappropriate.  Also, if the bill was correct, but you had not met your annual deductible, or had a co-insurance or some other obligation, then you actually may owe.

 

Hope this helps.

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Reading more on the thread, I see 2 distinct issues.

1) The appropriateness of the charges

2) Dealing with collections/credit report repercussions.

 

What was the descriptor of the, "surgery?"  What were the 5 digit codes billed?

 

Sure you can go to police, but it will go nowhere. My friend worked for a doc who was illegally, "upcoding"  and charging for services not rendered. Even met with the FBI, and had extensive interviews. The case went nowhere, incredulously. Since that "scheme" was <100K that she personally uncovered and reported, they didn't have time and resources for it.  They are off chasing the Bernie Madoffs of the world...Local police won't touch it. She could not become a qui tam whistleblower, since the doc did not bill out to Medicare or Medicaid.  The biggest take away from that whole drama was that the very best place to report suspected fraudulent billing is to your commercial insurance company. They are for-profit, and very interested in hearing about alleged fraud.

 

I agree with others that in-person, level-headed management, equipped with med recs is the best way to go.

 

As for #2. I'll leave that up to the pros. I'm a newbie at the whole collections world.

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Good info, thanks.  So, I have made some mistakes, but doesn't change the fact the doc wants way more than reasonable.

 

Codes:

 

99284-57 : Emergency Management Services.  My guess is charging $515 for looking at x-rays and talking to another doctor.

 

23620-54 : Fracture treatment without manipulation.  Essentially $1,132 for putting on a sling which took about 30 sec.  If this isn't gouging, what is?

 

The surgery part came from the insurance company paperwork, they're treating 23620-54 as a surgery.  I'd say it's a good idea to drop the surgery stuff.  Nope, no insurance company negotiated rates, everything is what the Doc is gouging me for.

 

The way I am seeing the billing, I'm being charged for 30 minutes of time spent on my case, then the luxury of the doc putting a sling on.  The bill is definitely gouging, I can't imagine a judge upholding 1,132 to just put a sling on.

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I can't imagine a judge upholding 1,132 to just put a sling on.

 

You imagine wrong.  The reality is the majority of people know that simply signing in to the ER for triage (evaluation) let alone treatment can automatically trigger a bill for a thousand dollars easily.  $1132 for diagnosing and treating the fracture even if it is just a sling is about right in most if not all ERs.

 

It isn't price gouging.  It is the reality of the medical model.  

 

23620-54 : Fracture treatment without manipulation.  Essentially $1,132 for putting on a sling which took about 30 sec.  If this isn't gouging, what is?

 

It isn't gouging it is coded wrong.  The 54 modifier/descriptor is what is telling your insurance company that it is surgery.  My educated guess is that the doctor did NOT use this modifier but that a coder at the facility got it wrong.  You need to get the facility to remove the 54 descriptor from this CPT code and it should correct the billing.

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So it costs the doctor, and only the doctor, $1,000 to put a sling on me?  Nope, it's doesn't   I still doesn't see a judge buying that.  If you're talking the facilities, Doctor, and x-rays being $1,000 together, then yeah I agree.  I already paid the facilities and x-rays, at least they were reasonable.  In WA, everything is billed separately.  Triage is billed in the management services per the bill's description, hence $1,132 just to put a sling on.  However you try to justify, $1,132 for just putting the sling on is freakin nuts.  No way will I pay for putting a sling on when $515 is being is being charged already.  The doctor and billing company are being greedy, plain and simple.

 

There just plain isn't enough to justify $1,600 for just the doctor, period.  Absolutely no doctor is worth $3,200 an hour, plain and simple.

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So it costs the doctor, and only the doctor, $1,000 to put a sling on me?  Nope, it's doesn't   I still doesn't see a judge buying that.  If you're talking the facilities, Doctor, and x-rays being $1,000 together, then yeah I agree.  I already paid the facilities and x-rays, at least they were reasonable.  In WA, everything is billed separately.  Triage is billed in the management services per the bill's description, hence $1,132 just to put a sling on.  However you try to justify, $1,132 for just putting the sling on is freakin nuts.  No way will I pay for putting a sling on when $515 is being is being charged already.  The doctor and billing company are being greedy, plain and simple.

 

There just plain isn't enough to justify $1,600 for just the doctor, period.  Absolutely no doctor is worth $3,200 an hour, plain and simple.

 

Well you are entitled to your opinion but I guarantee you that NO court is going to side with you.  Regardless of what you believe the reality is doctors are also in business and free to set their own fees as they see fit.  Your choice is to find a provider that charges less.  If the charge fits within the regional reasonable and customary fee for that CPT code all your protests and howling will not sway a judge one bit.

 

While I agree that they should code the care correctly so you are billed accurately as someone who has been in medical care for 30+ years I have taken care of far too many deadbeats like you who don't think they should have to pay for the care they receive.

 

The reality is the doctor is NOT making $3200 an hour.  The fees they generate also have to pay their staff, overhead, malpractice and a host of other expenses to keep providing care.  In reality many doctors earn about $50 an hour once they pay all the expenses to be in business.  Your treating physician didn't get the knowledge of how to treat your fracture by watching infomercials.  If treating it were so simple you would have done so at home.  You didn't.  You went to an emergency room for their time, expertise, and technology to diagnose and treat the condition.  You do not get to tell them what is reasonable to bill you for their knowledge and facilities to do their job.

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While I agree that they should code the care correctly so you are billed accurately as someone who has been in medical care for 30+ years I have taken care of far too many deadbeats like you who don't think they should have to pay for the care they receive.

 

Gee, thanks for showing how stupid you are.  I never said anything about not wanting to pay. I'm not paying unreasonable a mounts.  $3,200 an hour is outright unreasonable, regardless of how you want to justify the amount.  There is no way the doc is paying that much in other fees. He has no staff, no facilities to pay for, just insurance for his malpractice, the billing company he is with, his knowledge, and the 30 minutes he spent on the case.  That's not enough to justify $3,200 an hour, not even close.  But, I guess with what you said, you didn't pay attention to what was already paid.  If paying reasonable amounts makes me a deadbeat, guilty as charged.

 

I knw what I'm going to do.  Being a pain in the Doc's rear end is the least of his troubles so far.  Time to make life a little harder for him.

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I knw what I'm going to do.  Being a pain in the Doc's rear end is the least of his troubles so far.  Time to make life a little harder for him.

 

Before you embark on that plan you should consider that there is a "black list" for patients like you and once you land on it you won't find a provider who will agree to take care of you at any price.

 

Gee, thanks for showing how stupid you are. 

 

The one showing their ignorance is YOU.  This isn't about what is reasonable.  So far you have presented NO proof the amount is unreasonable except that YOU think it is.  Yes, it is coded wrong but that doesn't automatically make the bill amount unreasonable.  You balk at paying because you don't like the amount.  Well next time treat your own fracture then.  

 

Sadly I still deal with patients every week just like you who want the care and expertise but don't want to pay what the care is worth instead opting for their 1920s pricing model.  Or worse, they don't think they should have to pay at all.  Fortunately we can black list them which I hope they will do to you.

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Actually, the $1132 is reasonable for 30 minutes of 2 doctors time and putting on a sling, as well as nurses, as well as equipment, as well as the ER fees. The $515 is also reasonable for the X-Ray fees considering the equipment and technicians time. The only thing you might be able to argue is the cost of the sling itself but that is peanuts.

If I remember correct, about 8 years ago, a sprained ankle went about $600 - $800 at the ER and recently (< 1 year ago), 5 stitches in the hand went for $1200. And this is at the cheap, local hospital here, not the nationally known medical learning center which would have charged even more.

If it had been surgery, the charge would be been easily in the 5 figures so most judges will see that this was not surgery.

I think these charges are reasonable here.

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You're scenario may be reasonable, but for the scenario you came up with for my situation.  Everyone is not paying attention to everything except the doctor's time is already paid for.  In WA, the doctor bills separately from the hospital facilities which is billed separately from the x-rays.  Everything is independent of each other with independent billing departments/companies and each are independent companies themselves.

 

The Hospital charges covers facilities, any equipment used (IV, tubes, medications,the sling, bedding, bed time),receptionist, any surcharges for me screaming my head off for over 2 hours while the doctor had disappeared, and nurses, all of which was itemized out on the facilities bill.  Hospital facilities bill is already paid.  The X-ray bill covers the x-rays, the technician, and equipment use.  All that is paid for as well.  Heck, all that got paid for prior to the bills showing up since I knew where the bills would come from. I'm supposed to be a deadbeat?  The hospital facilities even cut my bill down by 60% because I paid early, was paying out of pocket, and they gave me some other kind of discount, all which I didn't ask for.

 

All that is left is the doctor wanting $1,132 to put a sling on by himself, with no help from anyone, not even another doctor.  It took about 30 sec to a minute to put the sling on.  Worst case the doc wants $135,840 per hour to put a sling on.  That's so unreasonable, I can't believe that's even an expectation for compensation.

 

$515 for services covers the phone call to another doctor, and diagnosing what's going on (triage essentially).  If the doc just asked for the $515, I would have gone with it and not made a big deal.  At that point the charges become more reasonable given everything that happened.

 

The $1,647 total billed from the doctor is just doctor time, nothing else.  I did talk to the hospital about that total, they can't even begin to believe that high of a total.  They confirmed all I am paying for is the doctor's time only on the doctor's bill.

 

I appreciate everyone trying to justify, and I agree with the justifications.  $1647 just for the doctor's time is just not reasonable for 30 minutes time, even up to two hours is unreasonable.

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And again, in your market, it may not be an unreasonable charge. I know onocologist around here that could easily charge $900 - $1000/hr if not part of a major hospital/clinic (and they get paid as an employee and I am sure the organization charges that much). An ER doctor may get even more based on the situation. If this is not an ER doctor, then he was probably on call and that adds a surcharge too.

This may not be as unreasonable as you think it is. If the hospital said that to you then odds are, this doctor is not attached to that hospital and hence, either has a private practice or was called in because of the time of the incident.

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Walking into an ER is taking up a critical spot for an amount of time.  They don't know that all you're going to need is your arm in a sling when you first get there and neither do you.  You want to make sure that it's completely assessed by someone who has spent thousands of their own money for years of med school, another couple of internship to be sure that you get the best medical treatment.  When they have found that it only needs a sling, it's like you feel that's all you should be required to pay is the part where he puts it in a sling.  

 

 

That's like agreeing to pay thousands of dollars for an ad spot during Super Bowl half time and then not wanting to pay the agreed charge when you realize all the people at home were in their kitchen making sandwiches during half time instead of watching your commercial.

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