Doctor's Bill - What do you think?

[moneybags]

I went for a "check-up" with my internist in November. My insurance covers an annual visit 100%. If I go to the dr. with a problem (sore throat, whatever), the visit is not covered until we reach our co-pay, which is pretty high. At my "check-up", I discussed a medical concern (migraines). The dr. billed me for 2 visits - the annual visit and a separate visit, based on the fact that I talked to her about other medical issues. Insurance covered the check-up but not the 2nd "visit". Now, I am sitting on a $170 bill that I don't feel like I should have to pay. I've called the dr. office, but they say, yes, that's how it goes. I'm thinking I should just pay the bill or it will end up in collections, but it just doesn't seem right. Thoughts?

[PrincessPerky]

It may be so, detailed in the fine print, or it may be the Dr has a way to get more money (the money for an annual checkup isn't much compared to the upkeep of an office)

Though regardless, you now know one major reason I avoid drs..I once went to the dr for a regularly scheduled maternity visit and asked about a rash on my hand (some rashes in pregnancy can signal bigger issues) happened to be Excema, something I never had before my pregnancy, nor any non pregnant time since...but since it wasn't a pregnancy issue, I was billed for seeing a specialist (Ob/Gyn are specialists).

However you may be able to call the insurance company to complain of one visit making two bills...you might want to tell the Dr first, as likely the sick visit will stand the well visit will be removed...so you will still pay 170, but the Dr wont get his insurance payment for the well visit...the dr office may decide to waive the 170... or not.

[disneysteve]

The dr. billed me for 2 visits - the annual visit and a separate visit, based on the fact that I talked to her about other medical issues.

I need to check with my biller, but I don't believe the doctor can bill for two visits at the same time. I think the proper way to do it would be to submit the bill for the highest level of service provided. In your case, that would probably be the evaluation of the headaches, rather than the routine check-up. So you would owe for that visit because it wasn't just a check-up.

[Scanner]

I need to check with my biller, but I don't believe the doctor can bill for two visits at the same time. I think the proper way to do it would be to submit the bill for the highest level of service provided. In your case, that would probably be the evaluation of the headaches, rather than the routine check-up. So you would owe for that visit because it wasn't just a check-up.

I have to agree with DisneySteve here.

I am trying to be diplomatic but from what I know about compliance in billing, what your doctor did was "abuse", maybe "fraud", but probably abuse (the two terms are legally seperate and carry different penalties - fraud is the more serious).

I know in the Medicare arena, that is considered "phantom billing" - billing for a visit for which you weren't there. As you can imagine, the Medicare people aren't the jolliest folks around when it comes to phantom bills. Neither is health or PIP.

I can't even bill you if I do happen to see you 2x in one day. IN my line of work, that sometimes happens - I get a "boomarang" patinet I see in the mornng and comes back in the night. I have to eat it, even though they took up 2 apt. slots in one day.

THe proper way to bill this would have been to simply upcode it as DisneySteve states to higher level of E/M, which means "evaluation/management" in the billing world.

I would say you contacted your insurance co. and let them know what they did was in error and to resubmit it the correct way (chalk it up to a mistake rather than something intentional). If the billing dept. gives you some resistance, ask for a "compliance officer" and that sort of language knows you mean business and your stuff.

[jodi]

I know this is besides the point (not billing related), but shouldn't you be able to discuss a medical concern as part of your check-up? Isn't part of a check-up for the doctor to ask you about any problems?

[disneysteve]

I know this is besides the point (not billing related), but shouldn't you be able to discuss a medical concern as part of your check-up? Isn't part of a check-up for the doctor to ask you about any problems?

When your doctor sees you, he needs to submit a bill to your insurance company (or to you if you are uninsured). That bill uses a standard set of evaluation/management codes and diagnostic codes known as ICD-9 codes. What codes he assigns to your visit will be based on what problems were addressed and what service was provided at that visit.

If you come in for an annual physical, and a physical is performed, the visit will be coded as a physical, with a specific code based on your age. If, however, he evaluates new complaints - headache, rash, back pain, whatever - he will use the codes that apply to those problems and that will alter the bill. If your insurance covers an annual physical but doesn't cover "sick" visits, you would be responsible for that bill. More commonly, I see patients whose insurance does not cover an annual physical, so if they come in wanting a physical, we won't code it as such if possible. We'll code it based on their chronic conditions or acute problems. For example, if they have high blood pressure or asthma, we'll use that code, rather than the physical code. If, however, they are in perfect health and there is no code we can legitimately use to justify the visit, they must pay for the physical.

[moneybags]

Thanks for the replies. I'll get on the phone next week. FYI - the check up cost was $277, the other visit was $180 ($170 after adjustment).

[mom-from-missouri]

Usually when I have my yearly checkup, the doctor will ask if I have any problems or issues. So, they way her doctor did it, if I were to speak up, and say yes, I'd get hit. My dr usually takes a quick look and them determines if I need to come back for that issue or not. (although lately, I was told it comes with getting older...)

[simpleyme]

wow i was not aware this could happen thanks for the thumbs up

when ,my second son was born I gave birth at shift change for the pediatrician on call and was billed by both Drs.

I was only in the hospital for 6 hours and the baby never left my room I called the drs and they both declared they had entered my room,I do remember one guy possibly a dr asking me if the baby was well and I said yes

the hospital said it was documented and i had to pay that was all there was to it,every question I ask was answered with its documented its documented

so I paid and hoped those SOBs felt great about literally taking food out of a babies mouth ,as our insurance refused to pay for such nonsense

[want2savebad]

So does this mean that a person should just stick to going to a GP unless they are referred to a specialist? Also should a woman when seeing an OB/GYN keep all underlying physical problems other than those they think might be related to situation at hand to themselves? Just asking, because I don't want to be hit with a ridiculous bill.

[disneysteve]

So does this mean that a person should just stick to going to a GP unless they are referred to a specialist? Also should a woman when seeing an OB/GYN keep all underlying physical problems other than those they think might be related to situation at hand to themselves? Just asking, because I don't want to be hit with a ridiculous bill.

I'm not sure what you mean regarding a GP or specialist. Generally, you see a family doctor (GP/FP) first and, if needed, get referred to the appropriate specialist.

As for a woman seeing her Gyn, I think that depends on the doctor. Some Gyns are comfortable handling other medical issues, some are not and prefer the patient to also have a family doctor. So I think you need to discuss that with your Gyn.

[Scanner]

wow i was not aware this could happen thanks for the thumbs up

when ,my second son was born I gave birth at shift change for the pediatrician on call and was billed by both Drs.

I was only in the hospital for 6 hours and the baby never left my room I called the drs and they both declared they had entered my room,I do remember one guy possibly a dr asking me if the baby was well and I said yes

the hospital said it was documented and i had to pay that was all there was to it,every question I ask was answered with its documented its documented

so I paid and hoped those SOBs felt great about literally taking food out of a babies mouth ,as our insurance refused to pay for such nonsense

Most people are not aware that there is a State Dept. of Banking and Insurance and they are purposefully commissioned to make sure insurance is doing their job and that insurance fraud/abuse isn't happening.

Most people want to go right for an attorney and generally, unless it's an auto accident, they are generally useless in such situations in representing you (because for them, there's no money in it).

If it happens again, tell them you intend to file a complaint with the DOBI. Now. . .they are supposed to be impartial. It won't always go your way.

A "shift change" sounds somewhat a gray area to me.

But in your case if you got double-billed for the same service. . .you at least had somewhat of a case.

Ask them to produce documentation. Yeah, they said, "they had documentation. It's documented." Trust me. . .I look at hospital documentation all day. Sometimes it's thorough. Most of the time it's marginal. I can tell you the pediatrician who came in and said, "How's your baby doing?" didn't have anything indicated in your record.

Of course, going back and adding stuff in happens all the time, unfortunately.

That's why. . .if you are really smart. . .you get hte documentation before you dispute. . .await for them to alter records. . .and wow. . .you really have them then.

Any time any doctor/institution alters records. . .you will prevail.

I am certain that for the most part, a hospital doesn't want a "case file assigned" in such an instance as it often means a lot of work, even if they come out victorious in such an investigation.

Your complaint could open Pandora's Box for them - if they are doing this to you. . .then what about the rest of women delivering babies?

It used to be a defense of "Well. . .I didn't know. . .insurance billing is so complex" (it is).

That defense is no longer legitimate. Medical billers are supposed to remain compliant with regulations.

[simpleyme]

good info

yes next time I will request the info and documents before making a complaint ,that is good advice

the hospital that did this is no longer in business I would like to think it was my boycott of them that did it ;-)

[Kedi]

when a medical provider sees a patient for a problem then there are additional problems the provider discusses, treats , etc at the same
office visit the provider CANNOT bill 2 separate office visits.

The provider bills 1 office visit because there was ONLY 1 office visit NOT 2
as previously stated there are levels of coding that take into account the level of care; ie time, complexity, etal so the provider is compensated for addressing more than 1 problem in 1 office visit
if your provider's billing dept does NOT get that I would ask to speak with the supvr
if the supvr does NOT get it let your insurance carrier deal with them

[moneybags]

As for a woman seeing her Gyn, I think that depends on the doctor. Some Gyns are comfortable handling other medical issues, some are not and prefer the patient to also have a family doctor. So I think you need to discuss that with your Gyn.

The reverse is also true. I have had 3 different GPs want to do my annual pap smear.