RN would like other opinions from nurses on this awkward MD/insurance issue

[pensivern]

I find myself in a situation I'm not sure how to handle. A couple of weeks ago I had my annual physical with my PCP. I've been going to this MD for about 3 yrs and initially chose him because he's convenient location wise, I can get an appointment with ease (at least with his Physicians assistant who is very competant), pleasant office staff and he's easy to talk to and has never given me a hard time with any prescription requests. I'm an RN so he's always appeared to have respect for my judgements/opinions on on what I need to remain healthy. We usually cut through the "BS" and commisurate on the sad states of affairs that is healthcare and insurance companies.

The last couple of years I've noticed he's been a lot more rushed-performing his physicals in (seriously) less than 2 minutes (patient fully clothed). I've chalked it up to him getting a bigger pt load or perhaps just rushing things with me since I'm a nurse and generally very healthy. I did comment to his medical assistant last time "wow-that man gives the fastest physicals ever). She reposnded..."Yeah, that's how he always is...." My husband goes to him too, loves him, but not being in the medical field maybe doesn't realize he isn't the most thorough examiner.

Anyway, after my 2 minute health assessment while he was checking off/ordering my annual lab work, I brought up a couple of health issues I had been experiencing over the past year but certainly didn't require a separate visit for. One query regarded the best treatment for a post-nasal drip, and the other was a ? about IBS. He recommended for one: Nasal spray....and two, a particular probiotic. The converstation lasted maybe another 2 minutes.

A couple of days ago I received my explanantion of benefits from my inurance company which showed a billing for my physical ($200) paid in full as my inurance covers 100% preventative care. I'm on a high deductible plan for sick visits but my employer will kick in the first 2K and I pay the final 1K before everything is paid in full again. If I DON'T use all of my company's share of deductible in 2010 that they kick in, it rolls over to 2011 account. This same explanantion of benefits also showed another $100 bill for a physican visit which a call to my insurance company revealed was for a 'sick' visit. The insurance company allowed $75 for the visit and was covered by my employer as I hadn't reached my 2k deductible mark yet.

I called my docs office to inquire why I was charged for a 'sick visit" as well as my annual physical and after browsing through my chart (MD wasn't in) they said it looked like we 'dicussed things out of the ordinary for a regular annual physical". WHAT?!?!? SInce when is it not appropriate to ask a few general questions about health issues during an annual visit? My doctor was obviously milking the system for a few extra bucks and probably not realizing he was screwing MY wallet because he didn't know about my particular high deductible policy. I know it's not alot of money we're talking about, but his billing for a 'sick visit' results in me getting $75 less put in my company's bank for the deductible they can kick in in 2011. Maybe I find it particularly irritating since my premiums for insurance are going up 30% in 2011 and my deductible portion rising from 1K to 1.5K.

The office staff I spoke to obviously isn't going to admit that he 'did wrong' in charging me for asking questions but I could tell from their voices they felt awkward in trying to justify his actions. They kept telling me I'll have to talk to him about it. He returns from vacation in a could of days.

I just don't know what to say when I speak to him. Should I be honest and level with him that I understand the frustration of the insurance industry but can't condone the 'milking' of it when it directly affects my wallet? I can't see him admitting such an act of wrong doing, yet I don't see how he can justify in words charging me extra for what should be included in an annual visit. He probably figured my inurance would pay for it in full and I would never notice. I really don't want to begin a search for another doc at this time and my husband wants to keep him also as his PCP. It's just very awkward and not sure what approach to take.

Any thoughts....suggestions....? Thanks for reading this long post!

__________________

[ChristineN, BSN, RN]

wow. For a true "sick visit" wouldn't he, by definition have had to examine your abdomen and sinuses better? Doesn't sound like this is the kind of dr to shine a light up your nose let alone do anything else. I would sign a release to see a copy of my chart if I was you, to see what exactly the dr charted doing. You could always show a copy of the visit note to the insurance company.

[ObtundedRN, BSN, RN]

Actually, this sounds correct to me. The yearly physical is strictly that. Anything other then a physical is in addition, and billed that way. I know they also grade the severity of your consultation/visit based on multiple factors. Part of that is the complexity of your illness/health history and another part is the number of things discussed.

The last time I had my annual physical, I asked my doctor for a couple additional blood tests. He suggested I come back on a second visit so they could be covered then and save me the money since they wouldn't be covered with the physical. I'm no expert of insurance claims and reimbursement, but this is my understanding of it.

[pensivern]

Actually, this sounds correct to me. The yearly physical is strictly that. Anything other then a physical is in addition, and billed that way. I know they also grade the severity of your consultation/visit based on multiple factors. Part of that is the complexity of your illness/health history and another part is the number of things discussed.

The last time I had my annual physical, I asked my doctor for a couple additional blood tests. He suggested I come back on a second visit so they could be covered then and save me the money since they wouldn't be covered with the physical. I'm no expert of insurance claims and reimbursement, but this is my understanding of it.

So, with that understanding, one should not speak during or after the physical about anything medically related lest they be charged additionally to the yearly visit? That just does not sound 'right' to me. The issues discussed were not even serious issues which might require (or didn't) further examination or even a consult with a specialist. With that reasoning, one also shouldn't discuss your periods, any issues re birth control or other GYN related problems during your annual GYN visit either if you expect to pay no more than a breast exam and pap smear (?) Now doesn't that sound ridiculous?

[sunkissed75, CNA]

That's crazy!!! I'm not going to pretend to understand how insurance is billed as I'm not American, but wouldn't it be cheaper to take up one visit with non essential questions? Otherwise wouldn't you then be paying for an extra visit to the Dr. office? Also, I agree that a yearly physical should include the types of questions you asked him about.

[kesr]

Ridculous, yes indeed. Stinks big time. But it is the face of insurance managed health care. If the insurance pays it is easy money for him. I audit medical records and most office calls make a point of documenting how much time is spent with a pt, how much time is exam, talking or teaching.

As you say, the doc may have thought it was covered by insurance and not your out of pocket. I'd ask him about it. Our insurance changed last year, our PCPs are not in our new network, but we are staying with them. He is careful to send us to in network labs and consolidate visits to minimize our cost. So far we don't get the bum's rush at visits.

On the other hand, if he is really dashing through patients, running a "meat market" he may be totally in making the maximum $$ mindset. In which case it may be time to find a new PCP.

[kanzi monkey]

Wow. This is hilarious, but not at all in a good way. (Dark humor). How 'bout this--why doesn't your Dr. actually PHYSICALLY EXAMINE you for your, ahem, annual physical exam? Then he might actually come across an actual finding that explains your complaints. And honestly, before he examines you, he should do a "review of systems", which is the subjective part of the exam where you have the opportunity to comment on each system if you feel the need. He should have gotten a few details about each of your complaints, then made recommendations. If he felt you needed a more focused exam, he should have recommended you make a follow up appointment, and then documented that. There's not any harm in making the recommendations that he made, but he most certainly is not "diagnosing and treating" anything. He can't diagnose you w/ IBS or PND just because you say you think you might have them.

In short--not a sick visit. If he's calling it a sick visit, he diagnosed you with something. If he documented that he diagnosed you with something and got paid for it, without doing a focused exam, he is full of it.

I'm sorry this happened to you. My recommendation--tell him to change how he billed you. Then seek a new PCP.

Good luck!

[tyvin, BSN, RN]

You really need to put yourself in their shoes. With reimbursement rates from Medicare and Medicaid being what they are the docs got to nickel and dime to break even. You did go out of the scope of the physical asking advice about other concerns.

As far as the physical not taking as long as you think it should; when you know your patient and you're experienced it really doesn't take that long. Remember he is accessing your musculoskeletal system as you talk and your cognitive skills as he talks to you so tap tap and a good doc will be done in no time. Don't hold your breath for the cranial nerves to be tested one by one; there are a hundred ways to access those without resorting to the old and true.

Talk straight with him and I think you may just agree with him and also bring up the fact that you are uncomfortable about his recent skills concerning the physicals, perhaps he can explain things.

[kesr]

If he's calling it a sick visit, he diagnosed you with something.

Actually, since he did write a prescription there is a diagnosis code attached to that; ergo no longer a well pt physical. Still sucks - and I have heard from other folks they received their "physical" fully dressed. I guess only gyn's go for skin!

[linearthinker, DNP, RN]

Sounds like very appropriate billing based on ICD9 codes IMO.

[ebear, BSN, RN]

OK. So Medicare and Medicaid pay poorly. Does that mean that those with insurance are supposed to get screwed? I think not! Can you say "insurance fraud"? Ask him why you were charged for a sick visit at the time of your supposed "physical exam" and watch him squirm.... then go elsewhere. No wonder our premiums are through the ****** roof! It's ridiculous.

[ObtundedRN, BSN, RN]

Sounds like very appropriate billing based on ICD9 codes IMO.

This is what I was referring to. I always wondered what the 1-5 code was when they circle the severity of your visit. So when I looked it up, that is what I found out. Its based on things such as how much time is spent with a pt, how many complex medical conditions are treated, how many minor conditions are treated, any diagnostic interpretation, and maybe some other things. So yeah, when you went out of the scope of a well visit, he billed accordingly. Considering it only added an extra 2 minutes to your talk and it wasn't anything of real importance, I guess a doctor could choose not to bill for it. But if he is going to take the liability of giving you medical advice for the questions asked, I don't see why its unfair for him to bill for it.

As for him not taking enough time with you and not doing a full physical, either advocate for yourself and ask for the attention you deserve, or find a new PCP.