Charged for medical visit at yearly physical?
September 23, 2024 12:09 PM Subscribe
I went for my insurance-covered yearly physical, and was charged for a medical visit as well. I am familiar with the stipulations that you can't talk about any health issues at your physical, but I answered only questions asked by the doctor and there were no changes to existing medications or treatments. Is being charged for providing 'no change' status on existing conditions expected and I mis-understood the current rules? Or should the doctor have documented things differently?
I sent a request for review to the billing department and they said 'per the visit record' it was correctly charged. I called and asked what specific part of the visit caused the charge, and they couldn't/wouldn't tell me, they just said it's in the visit record. They said if I wanted to dispute further, I could 'amend my record' to remove whatever I wanted (assuming I knew what it was), but it's not clear that would matter in the being charged, it doesn't seem likely I can ask to have everything removed and then re-evaluated by billing and get the medical visit charge removed? I thought about disputing with my insurance but was afraid they'd refuse to cover it and then I'd just get charged the un-discounted rate.
Did I misunderstand how physicals work now? The record shows my existing conditions noted outside of the 'physical' item list, but I literally answered questions about how work is (less stress this year), if I had started taking a newly prescribed statin (yes), and if I was still taking migraine medicine 'as needed'(yes).
In brief:
1) Did I misunderstand the rules for physical exam coverage these days and should just pay up?
2) If it was incorrectly charged, what's the next step to fix it? It's not a hardship I'm just annoyed and frustrated, and I probably don't have bandwidth to follow up unless it's straightforward.
3) How do I avoid being charged next year? I'm supposed to answer no questions from my doctor??
I sent a request for review to the billing department and they said 'per the visit record' it was correctly charged. I called and asked what specific part of the visit caused the charge, and they couldn't/wouldn't tell me, they just said it's in the visit record. They said if I wanted to dispute further, I could 'amend my record' to remove whatever I wanted (assuming I knew what it was), but it's not clear that would matter in the being charged, it doesn't seem likely I can ask to have everything removed and then re-evaluated by billing and get the medical visit charge removed? I thought about disputing with my insurance but was afraid they'd refuse to cover it and then I'd just get charged the un-discounted rate.
Did I misunderstand how physicals work now? The record shows my existing conditions noted outside of the 'physical' item list, but I literally answered questions about how work is (less stress this year), if I had started taking a newly prescribed statin (yes), and if I was still taking migraine medicine 'as needed'(yes).
In brief:
1) Did I misunderstand the rules for physical exam coverage these days and should just pay up?
2) If it was incorrectly charged, what's the next step to fix it? It's not a hardship I'm just annoyed and frustrated, and I probably don't have bandwidth to follow up unless it's straightforward.
3) How do I avoid being charged next year? I'm supposed to answer no questions from my doctor??
I'm married to medicine, and this is also frustrating to providers. They are being pressured into billing as high as they can justify, and in many cases, the insurance providers will cover the other things and the patient will not have an additional cost, so this seems somewhat reasonable to them.
You can try to make it clear to your provider that you want to stay within the framework of the annual exam and any additional workup will cost you money you can't spend. If you have a compassionate provider, they will likely not submit for additional billing.
Now, this does sometimes get upcoded by the billing department based _on things no one can give you reasonable guidance on_ and is frustrating to all involved. Sorry the system is so broken.
posted by advicepig at 12:27 PM on September 23 [1 favorite]
You can try to make it clear to your provider that you want to stay within the framework of the annual exam and any additional workup will cost you money you can't spend. If you have a compassionate provider, they will likely not submit for additional billing.
Now, this does sometimes get upcoded by the billing department based _on things no one can give you reasonable guidance on_ and is frustrating to all involved. Sorry the system is so broken.
posted by advicepig at 12:27 PM on September 23 [1 favorite]
Possibly relevant:
https://www.ama-assn.org/practice-management/cpt/can-physicians-bill-both-preventive-and-em-services-same-visit
It seems that if the E/M ("office visit") services required additional work beyond the preventative visit, they should be billed. Doesn't seem like verifying your medications and asking about work stress would incur "additional work" but this may give you a starting point for arguing with the billing dept.
posted by basalganglia at 12:55 PM on September 23
https://www.ama-assn.org/practice-management/cpt/can-physicians-bill-both-preventive-and-em-services-same-visit
It seems that if the E/M ("office visit") services required additional work beyond the preventative visit, they should be billed. Doesn't seem like verifying your medications and asking about work stress would incur "additional work" but this may give you a starting point for arguing with the billing dept.
posted by basalganglia at 12:55 PM on September 23
Decline to pay it based on insufficient information, tell them you're doing this. The idea that you can't discuss your health at an annual visit is fairly new and I find it bizarre.
posted by theora55 at 1:47 PM on September 23 [2 favorites]
posted by theora55 at 1:47 PM on September 23 [2 favorites]
Best answer: This happened to me this year. Like you I did not bring anything up, just answered questions.
I just kept calling insurance and the doctors office again and again and again asking politely for it to be explained and for more detailed documentation to be sent and asking to be escalated to the next higher up person.
I was actually fairly certain I was going to end up paying the $250 in the end but I was so mad I was determined to make them spend more than that on answering my phone calls.
To my great surprise they eventually gave up and removed the charge!
I'm still mad though. I'm probably going to give up physicals because of it.
posted by Jenny'sCricket at 3:08 PM on September 23 [3 favorites]
I just kept calling insurance and the doctors office again and again and again asking politely for it to be explained and for more detailed documentation to be sent and asking to be escalated to the next higher up person.
I was actually fairly certain I was going to end up paying the $250 in the end but I was so mad I was determined to make them spend more than that on answering my phone calls.
To my great surprise they eventually gave up and removed the charge!
I'm still mad though. I'm probably going to give up physicals because of it.
posted by Jenny'sCricket at 3:08 PM on September 23 [3 favorites]
Yeah this is a new thing, it's common, it's bad, and I strongly agree with Jenny'sCricket and kschang about your next steps. Your insurer may be willing to step in and/or help push back, plus annoying the billing office does sometimes work.
posted by peppercorn at 3:25 PM on September 23
posted by peppercorn at 3:25 PM on September 23
> disputing with my insurance but was afraid they'd refuse to cover it and then I'd just get charged the un-discounted rate.
99.9999% of the time insurance will underpay with the idea that few people will dispute. So it is automatic $$$ for them. Many times they will then relent even with the simplest dispute of charges. This is their whole scheme to improve profits so it is worth understanding it and also being willing to dispute far more often than most of us do.
Here is one article - just a sample of how the system often works now.
posted by flug at 7:36 PM on September 23
99.9999% of the time insurance will underpay with the idea that few people will dispute. So it is automatic $$$ for them. Many times they will then relent even with the simplest dispute of charges. This is their whole scheme to improve profits so it is worth understanding it and also being willing to dispute far more often than most of us do.
Here is one article - just a sample of how the system often works now.
posted by flug at 7:36 PM on September 23
Welcome to one of the latest trends in maximizing income by healthcare provider companies (which are increasingly owned by private equity firms).
They have decided that, rather than fight the egregious practices of the healthcare insurance industrial complex, they would rather put the squeeze on their patients/customers. Hence, things like "upcharges" for purportedly free annual exams, and requiring chargeable office/video/phone visits for simple questions, or to get a prescription for a known condition that you've been getting Rxs for, for years.
It might help in the future to tell your provider at the start of the visit, something like: "In today's annual exam, we can only discuss what will fall under my insurance company's 100% covered provisions."
posted by concinnity at 1:51 AM on September 24 [3 favorites]
They have decided that, rather than fight the egregious practices of the healthcare insurance industrial complex, they would rather put the squeeze on their patients/customers. Hence, things like "upcharges" for purportedly free annual exams, and requiring chargeable office/video/phone visits for simple questions, or to get a prescription for a known condition that you've been getting Rxs for, for years.
It might help in the future to tell your provider at the start of the visit, something like: "In today's annual exam, we can only discuss what will fall under my insurance company's 100% covered provisions."
posted by concinnity at 1:51 AM on September 24 [3 favorites]
Best answer: IAAD. The way that billing has always worked in every setting where I've practiced: I see a patient, I assign a billing code based on a very basic/rudimentary system (I basically use one of a very small handful codes that apply to the types of visits I see—I don't spend a lot of time thinking about billing because I prefer thinking about medicine), and then some time later my health system's billers read the chart and assign any other billing codes that they think are appropriate based on what is documented in the chart. "Appropriate" in this context means what the billers think they can get the insurance company to pay for based on what is documented to have happened in the visit.
The upshot of all of this is that most of the time your doctor has no idea and no control over what you are ultimately going to be billed for. If a patient gave me concinnity's line, I would have to tell them honestly that I'm not able to make that guarantee because I am not in charge of billing and I'm not an expert in what their insurance company covers 100%.
Similarly, the fact that you answered the doctor's questions probably has nothing to do with what you were billed for. I would not worry about policing your behavior in the future. This is about the unfortunate business of healthcare which has become extremely focused on using non-physician administrators to squeeze extra compensation out of care that is being delivered anyway. For every patient like you who is genuinely distressed by an extra charge, there are many patients who either cough up the extra money without thinking about it or insurance companies that simply cover what was billed without the patient finding out.
There is a good shot you will achieve your goal of not paying this bill by being pushy with the billing department; I would simply repeat this was an annual physical, that's what was scheduled, that's what took place, and you were billed for other services in error. Sometimes you have to just keep calling until you get to talk to a different person, sometimes you have to keep calling until you've annoyed the person answering the phone enough.
posted by telegraph at 5:15 AM on September 24 [5 favorites]
The upshot of all of this is that most of the time your doctor has no idea and no control over what you are ultimately going to be billed for. If a patient gave me concinnity's line, I would have to tell them honestly that I'm not able to make that guarantee because I am not in charge of billing and I'm not an expert in what their insurance company covers 100%.
Similarly, the fact that you answered the doctor's questions probably has nothing to do with what you were billed for. I would not worry about policing your behavior in the future. This is about the unfortunate business of healthcare which has become extremely focused on using non-physician administrators to squeeze extra compensation out of care that is being delivered anyway. For every patient like you who is genuinely distressed by an extra charge, there are many patients who either cough up the extra money without thinking about it or insurance companies that simply cover what was billed without the patient finding out.
There is a good shot you will achieve your goal of not paying this bill by being pushy with the billing department; I would simply repeat this was an annual physical, that's what was scheduled, that's what took place, and you were billed for other services in error. Sometimes you have to just keep calling until you get to talk to a different person, sometimes you have to keep calling until you've annoyed the person answering the phone enough.
posted by telegraph at 5:15 AM on September 24 [5 favorites]
Best answer: You should get an EOB from your insurance company that should lay out what you are charged for. The EOB should contain one or more billing codes. You can then google these codes to see what they charged you for and you can determine which one is inappropriate. Then you have to bother the doctor again to rebill without the invalid code. But if you have the code to give them, that makes the process much simpler. That's probably going to be the simplest fix. Any code with a definition that includes preventative should be free (generally speaking), so you're probably looking for the outlier.
posted by possibilityleft at 6:33 PM on September 24 [2 favorites]
posted by possibilityleft at 6:33 PM on September 24 [2 favorites]
The idea that you can't discuss your health at an annual visit is fairly new and I find it bizarre.
Wellness visits not getting billed to patients is equally "fairly new" since it's the same provision in the Affordable Care Act that causes the "can't discuss your health at an annual visit" situation in first place. What's "bizarre" is assuming doctors wouldn't change their behavior in response to a mandate to offer certain services at no cost.
posted by Back At It Again At Krispy Kreme at 12:08 PM on September 25
Wellness visits not getting billed to patients is equally "fairly new" since it's the same provision in the Affordable Care Act that causes the "can't discuss your health at an annual visit" situation in first place. What's "bizarre" is assuming doctors wouldn't change their behavior in response to a mandate to offer certain services at no cost.
posted by Back At It Again At Krispy Kreme at 12:08 PM on September 25
I should add, as telegraph alludes to above, that when it comes to anything money related, "doctor" really means "the people in the billing department". So, while your actual doctor might not know or care what services are covered or not or at what cost, the people paying the rent certainly do, and they are incentivized to bill in a way that that ensures enough money is coming in.
posted by Back At It Again At Krispy Kreme at 12:12 PM on September 25 [2 favorites]
posted by Back At It Again At Krispy Kreme at 12:12 PM on September 25 [2 favorites]
Response by poster: Update: I called my insurance hotline as suggested, and to my surprise they were really great. He immediately called the billing department but since I had already asked for a review he wasn't able to get another review based on what he thought was over billed, so next time I would definitely start with them and not the medical billing department.
I submitted a request to have the parts of my visit record removed that I think resulted in the extra billing, I don't expect success with that but I was also able to find the billing code which indicated a '20-30 min consultation' which definitely didn't happen, so once the visit record update is denied I plan to call back with that information at hand and see what happens.
posted by lemonade at 10:28 PM on October 29 [2 favorites]
I submitted a request to have the parts of my visit record removed that I think resulted in the extra billing, I don't expect success with that but I was also able to find the billing code which indicated a '20-30 min consultation' which definitely didn't happen, so once the visit record update is denied I plan to call back with that information at hand and see what happens.
posted by lemonade at 10:28 PM on October 29 [2 favorites]
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posted by kschang at 12:22 PM on September 23 [5 favorites]