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!
It is standard practice to bill ICD9 codes as applicable. If sinus conditions were discussed, it is appropriate to include the code and bill for it. It is natural for that to be regarded then as a sick visit. I see why the OP is frustrated and disappointed by that, but that's just the way it is. I can't blame the guy for trying to make a living. I would have a huge problem with his exam technique if it is as poor as it sounds. For that reason, regardless of billing issues, i might find a new PCP.
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.
It isn't fraud, it's standard practice. Every condition addressed is itemized by a code and each code is reimbursable. He is correct to bill for any condition addressed in the visit. If it included anything other than a PE, it meets criteria for a sick visit. If you don't like the way the currrent health care system is set up, write your congressman, I hear they are working on it.
Here, check out this site http://www.aafp.org/fpm/2005/0900/p52.html. It may help a little. Like I said, I don't know much about billing and reimbursment. I'm a nurse, I don't care how much it cost if it means I can properly care for my patient :).
Look up the codes 9920x and 9921x. Where the "x" is replaced with a 1-5 depending on the complexity of the case. I believe the 9920 is for new patients or conditions, and the 9921 is for established.
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.
.
No one has any idea if it was of "real importance" because no one did a physical exam. Also, lactobacillus and saline nasal spray are available OTC. Neither is standard treatment for diagnoses of PND or IBS. Both of these diagnoses have some underlying cause that should be worked up if a provider is going to link them to a treatment. (OP, I'm not saying anything about your diagnosis--these meds may help with transient sinus/GI symptoms. But if you're concerned about what's causing these symptoms, you should get evaluated)The "scope of a well visit" does not require that a patient is well--it only assumes that the patient is not seeking treatment for a specific complaint. This is the POINT of a well visit. If a provider picks up on a complaint or physical finding that indicates that the pt may actually be "unwell"(ie, SBP is 210, or random glucose is 188)--they need to make a plan for it. Usually a next available follow-up visit, maybe with plans for further testing in the interim (ie, labs taken that day, or imaging studies prior to follow up). Unless all the appropriate testing, diagnosis and treatment is done during the one visit, nothing should be different as far as billing is concerned.
What if a young patient presented for her annual PE and during her ROS she mentions that she's been having a lot of head aches lately that have been interfering w/ her daily life. Say the doctor said "hey, try Tylenol for your headaches". No other assessment or plan is made. Because he wrote a paper prescription for Tylenol (so she could have a larger supply for the price of a cheap co-pay--or, the cynical reason, the doctor is coddling the patient thinking she'll feel she got treated well if she leaves w/ a script in her hand) the doctor bills for an "episodic visit" w/ a generic diagnosis of "headache". 3 weeks later the local hospital calls requesting medical records for this pt, who was recently admitted w/ seizure activity and a mass on her head CT. This would be a bad scene for any PCP.
OP, if what you say is accurate--that you were not actually evaluated for a diagnosis that was made for you--your PCP did a poor job reflecting your acuity in his billing practice. It doesn't matter why. The point is, you have a right to adequate medical care. Tell this PCP and your insurance company that you do not believe you were billed accordingly, and find a new provider.
Specializes in Med-Surg/Peds/O.R./Legal/cardiology.
I understand ICD9 codes but this is taking it too far. A patient should be able to ask a few simple questions during the routine physical exam. If a problem is more complex, then of course another appt is necessary. Why don't they just charge you every time you open your mouth?
I understand ICD9 codes but this is taking it too far. A patient should be able to ask a few simple questions during the routine physical exam. If a problem is more complex, then of course another appt is necessary. Why don't they just charge you every time you open your mouth?
Those concerns really should not have been included in a PE. It isn't fair to the provider. I understand you don't like the system, and I'm inclined to agree with you. However, working within the system we have, such as it is, he was not wrong to bill you the way he did. He was wrong to do an inadequate exam though, and this is the real issue IMO.
I'm not an RN, yet, but I can empathize with this, however, my experience is with a dentist...
Back in July, I had a tooth pulled. It had broken, and my insurance doesn't cover a cap on a molar, so it had to be pulled because at the time I couldn't afford it out of pocket. So, the tooth was broken, but still in decent enough condition that it could just be pulled, no surgery required.
I called and made the appointment, I had to wait 2 weeks with a broken tooth and live on jello, pudding, etc. for these 2 weeks... Anyway, I went in for my appointment, the assistant took a few xrays, and I was put in a room. I waited for about ten minutes before he came in, flipped the chair back, and shot the novacaine (spelling?) in my gums. He left for another five minutes. When he came back, he flipped the chair back again and grabbed an instrument that looked like two spoons that had been welded together! He grabbed my tooth and a few seconds later, it was out. A wad of cotton was shoved in my mouth and I left with my prescription for lortab.
So, my dental insurance is 60%, except for emergencies which is 75%. (They consider an emergency to be an infection that threatens the bone structures, etc.) I pay my deductible at the beginning of the year, and after they bill the insurance, the office sends me a bill for the remainder, which I send out a check for after I get the bill.
Anyway, last week, I got an EOB from my insurance and much to my confusion saw that the insurance company was not going to pay for my surgical extraction. Only one problem, I've never in my entire life had a surgical extraction on a tooth, EVER! I called the insurance to clarify what they considered surgery, the operator told me that it requires full sedation and cutting of the gums followed up by sutures. When she found out that none of that happened, she told me not to worry and that they would investigate.
The next day, I called the dentist's office to see what was going on. The receptionist refused to let me speak to the dentist or the person in charge of billing, etc. She, the receptionist, told me that it was between the the dentist and the insurance company and none of my concern. I calmly told her she was full of crap and that I wouldn't be returning to someone who cannot bill for a simple procedure...
(The worst part is the dentist is the pastor of a church I used to attend.)
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 think it is ridiculous that they told you that you have to speak to the doctor directly about it. They should be able to explain it to you. Can you ask to speak to the office manager? (or maybe you already did) or the doctors billing department, some if not most docs have a billing company that does the billing for them and you can have them explain it to you.
My younger sister went for a physical by herself she recently turned 19. She had a physical and then talked about a cough. The doctor coded as a physical and a sick visit and my parents insurance would not cover the cough part of the visit the reason being"two visits to same provider in one day" If she went back the next day it would have been covered.
After phone calls to the medical group they gave her a one time pass on needing to pay. So now we all know to not bring stuff up at a visit or ask our ahead of time provider how it is going to be coded. They said they recently started aligning their billing practice with those that medicare uses.
By the way they called this kind of thing "by the way visits" You go for a back problem and "by the way I have a mole I need you to look at, by the way I've got wax in my ear that needs irrigating" Lots of people do this kind of thing. But if you do it now you will be dinged.
I'm a CPC, and I'm going back to school for nursing. I was working for a local group doing their coding. The rule we were given (and our docs were given) is that if anything is brought up during the yearly visit it is billed seperately. BUT, from what I was told, Medicare (and many insurance companies are following) is no longer covering a "sick" visit and a physical in the same day. SO; my coding manager explained to the docs that it is up to them to decide. If a pt comes in for a physical and brings up another issue, they can do a "sick" visit and ask the patient to come back the following week for the physical. Most of our docs disagreed because they hated asking a pt to come back when it can be handled in one visit, but the last I've heard (I left to go back to school) they are supposed to be asking the pt to come back for a second visit.
But, unfortunately, that is the correct way to bill it.
So you better be healthy and ask no questions during an anual well person check up? Kinda defeats the purpose.
Had the same type of issues with my ped. Last baby was very tiny at birth. Went in for the first week check up and she was down a bit of weight but I was nursing and some wt loss is expected. I have plan where the first year $1,500 in well baby checks are covered at 100%. I thought nothing of it when the doc said to bring her back in 3 days for a weight check. Turned out it was billed as a sick visit and cost me $80 just to have her weighed. I could have done that for free at the grocery store, but you know how frazzled new moms are (I had 4 more at home and my house was torn up for construction and Yada, yada yada)
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.
linearthinker, DNP, RN
1,688 Posts
It is standard practice to bill ICD9 codes as applicable. If sinus conditions were discussed, it is appropriate to include the code and bill for it. It is natural for that to be regarded then as a sick visit. I see why the OP is frustrated and disappointed by that, but that's just the way it is. I can't blame the guy for trying to make a living. I would have a huge problem with his exam technique if it is as poor as it sounds. For that reason, regardless of billing issues, i might find a new PCP.