Until recently, our family was on a high premium / low deductable insurance plan. A trip to the doctor would set me back $20.00. The problem with the plan was that the premiums were going up, up, and up. Last year I took a serious look at the low premium / high deductable plan and after some serious consideration, we switched.
In a nutshell, my premiums are pretty low (compared to what I was previously paying) but the exchange for that is we pay the first (roughly) five thousand dollars out of pocket. Completely. No co-pays, no deductions, nothing. I pay the FULL amount of the cost of a office visit, urgent care, emergency room, or hospital visit, but thankfully we are allowed annual check ups at no out of pocket expense. It sounds pretty ominous, but truth be told, the premiums on the other plan cost us more than the maximum out of pocket expense for the current plan. So far, it has generally worked out for us.
Last week we received a pretty significant medical bill. It came from our kids’ regular clinic. The bill covered one office visit, and two check ups – so I assumed there may be some sort of error in the billing. I talked with the Mother of Five about the various visits – and determined that we did indeed have one office visit (billed), and two check ups (non billed) – and that during one of the check ups a “procedure” was done. This caused the one “check up” to become an “office visit”. Considering the fact that an actual procedure was done (equipment and supplies) I was willing to pay for that but the overall bill was still too much.
I called the Medical Billing company. They could not help but referred me to the insurance company.
I called the insurance company. They could not help but referred me to the clinic.
I called the clinic. The office manager could not help me but referred me to someone called a coding specialist. The coding specialist would be given our case for review and then call us back. Roughly a week later, the coding specialist did call me back.
Boy oh boy did I learn a few things.
What it boiled down to was this. Yes, a “check up” has no out of pocket expense for the patient, UNLESS you and/or the doctor actually do or say anything other than… well… pretty much ANYTHING.
Want a no out of pocket expense check up? Go in and keep your yap shut. Don’t ask any questions, and don’t answer any either. And if you have anything wrong with you for goodness sake, DO NOT BRING IT UP! It would seem that a check-up is NOT for discussing your medical health.
The particular patient in question has had an ongoing problem with nasal congestion resulting in a number of sinus infections over the past two years. Sinus infections that have been treated by the same physician that was doing the annual check up. During the check up, the physician asked my wife how the sinus infections were going (remember, this was brought up by the physician). My wife told the physician that there were still some lingering effects, but nothing significant. The physician then prescribed one more round of meds to hopefully finally free her from what was causing the infections. The whole interaction with the physician about the sinus infection took less that three minutes. It was one question asked, one answer given, and one prescription re-issued. My wife never gave it any thought before, during, or after the exam.
The coding specialist explained to me that the three minute discussion (even though initially brought up by the physician) is what resulted in a $150.00 medical bill. The act of writing a prescription caused the physician to (and I quote) “make a decision”. The act of making any sort of decision during a annual physical will result in that office visit getting doubled coded as the “check up” and as an “office visit”.
Don’t forget folks… This $150.00 is on top of the amount that the insurance company is paying the clinic for the check up. Just because there is no out of pocket expense for me does not mean the clinic is doing the check up for free.
She also went on to explain to me that it does not even have to be a “procedure”, or a “decision”. If we even discussed anything about the patient’s health it may result in additional coding (and billing).
During my “lesson” I asked the coder how my wife could have / should have answered the physician's question that would have prevented the bill. She had no concrete answer. I asked her why the physician did not stop my wife from answering, or warn her that by answering that one simple question, we would be billed for an office visit. She had no concrete answer. I asked her if (in the future) we should simply be deceitful about our health when it comes time for the check ups. She didn’t say no! She told me that “I can’t tell you that’s what you should do”.
“Turn your head and cough??” Nope. This feels a lot less like a hernia exam and a heckuva lot more like a procto-exam.