What am I doing wrong at the doctor's office?
November 10, 2011 9:48 AM   Subscribe

I have a doctor's appointment coming up in the next few weeks. I have healthcare coverage, but I always seem to end up with a decent sized bill anyway, even for appointments that seem to be covered. What are you supposed to say and do to avoid this? This gets rather long inside.

I have a high deductible plan at uhc. I have a doctor’s appt coming up, scheduled as a checkup, in network. In the past, with this plan and others from other plan providers, I would go I got to the doctor’s office for my checkup and something I said or did always seemed to lead to me getting charged for the visit even though checkups and office visits are supposed to be covered.

I am not trying to do anything shady here. It just seems there is something I am saying or doing that changes it from a covered checkup to "brought some problem in, now lets charge furious for everything". It is not specific to a plan or a location, those have changed over the years.

I did a calculation at the plan website, and it says office visits, even extended ones, are covered. But then if you need treatment of some sort, it seemed to sometimes suggest that you'd be paying out of pocket bigtime.

Are you supposed to just talk about any symptoms like they emerged that day?
Are you supposed to let the doctor discover things on their own?(as in, don’t say “I think I have the flu", just say "on the way into your treatment room I developed a hacking cough”)

If I have pain, should it have just started just as I walked in?
If I have pain in my wrist (I don’t), should I let the doctor examine it and then say ouch when he/she gets to it? Like if the doctor diagnoses or finds it themselves, does that get it categorized as something insurance is supposed to pay, rather than something to toss the way of the patient?
If I ask for a test, is that different than if the doctor orders a test?

I feel like I have insurance when I walk in, and I don't when I walk out. I'd have to fall from a hot air balloon to hit my deductible, but that shouldn't even come into play because standard visits are supposed to be covered. If my coverage is "go to the doctor but you can never have anything wrong", well that makes no sense as coverage, right? If I am assumed to never need medical care, I do not need to go to the doctor, and therefore I have no coverage. Further, if I have no coverage when I a have an ailment, then what is the point?

So I figure that when I get into the doctor's office, there is something I am doing or saying wrong, that leads me to getting sent bills for $150. What is the trick is to avoiding being charged?
posted by furious to Health & Fitness (21 answers total) 5 users marked this as a favorite
1. Are you sure you have met your deductible?
2. Are you sure the doctor's office is submitting claims to your insurance?
posted by desjardins at 9:54 AM on November 10, 2011

What is your deductible amount? Does your insurance let you do a copay (flat fee) for a visit, or is it coinsurance (a percentage of the cost of the office visit)? Are you expected to file a claim or is your provider billing the insurance directly?
posted by trunk muffins at 9:56 AM on November 10, 2011

Best answer: You should check the details with your plan, but it sounds like maybe your plan covers annual well visits for preventive care but doesn't cover problem-focused visits. Well visits usually involve talking about staying healthy, diet and exercise, maybe some routine blood work like cholesterol depending on your age and other medical problems, and referral for age-appropriate screening tests like mammograms and colonoscopies. The minute you bring up things that are bothering you, you have added a problem to your well visit, which changes how it's billed. This may be why you're getting bills. You can check with your insurance company to ask them exactly what's covered and what isn't, or maybe ask the billing people at your doctor's office how they are billing the insurance for the visit.
posted by The Elusive Architeuthis at 9:58 AM on November 10, 2011 [3 favorites]

Sometimes insurance distinguishes between checkups (often covered once a year) and consultations (when you go in for a specific problems). So when you say "standard visits are covered" but that your visits change from "a covered checkup" to 'brought some problem in'", it makes me think that perhaps your insurance allows you one covered annual checkup/physical before you hit your deductible, but that other consultations for specific issues are not covered below your deductible.

I believe if you have scheduled an annual checkup and there's a specific issue to discuss, that wouldn't automatically change the nature of the visit as far as your insurance coverage. But you probably should talk to your insurance company to clarify what is/is not covered--they'll be able to give you the straightest answer.
posted by drlith at 10:03 AM on November 10, 2011

If my coverage is "go to the doctor but you can never have anything wrong", well that makes no sense as coverage, right?

Actually, I think that's the idea behind a high deductible plan. The reduced coverage is what you get in exchange for a lower monthly premium.
posted by ThePinkSuperhero at 10:03 AM on November 10, 2011 [5 favorites]

It sound like you really don't understand your insurance policy. Review it closely to see what's covered and what's excluded and what services count towards your deductible. For example, for women, pap smears may be covered but a urinary tract infection may have to be paid for out of pocket until the deductible is reached. Same with a well baby visit and vaccinations - covered, but an ugly rash or fever - not covered and payment counts toward your deductible.

You may have chosen the wrong kind of insurance plan for your needs. High deductible plans are for people who are really healthy and only expect to go to the doctor for a yearly check up or have an accident. I have asthma and such a plan would never work for me. And I like having easy, relatively inexpensive access to healthcare.
posted by shoesietart at 10:14 AM on November 10, 2011 [2 favorites]

Best answer: The thing to do here is to talk to the person in the front office when you check in and ask specifically "how am I going to be billed for this visit today?" and then go over that again with your doctor. Alot of doctors will also bill "strategically" as long as you make it super clear that you checked and your insurance covers billing code or reason XXX but not YYY, so can we bill for XXX today? That is within reason of course; they're not going to bill you for some super cheap test if they actually did a really expensive test, but if the difference amounts to semantics or arbitrary codes and numbers and not a real difference in time or cost, they should be willing to help make the visit look billable if you provide them the right info. They want money, and if they can easily get it from your insurance, they'll be happy to do that for you.

Of course if your insurance website says only wellness visits are covered and they have a strict definition of that in the billing codes, there is no way your doctors office can get around that or get any diagnostics or medication covered. That's why you have a high deductible and low premiums. If you actually want stuff covered that usually comes with a bigger premium.
posted by slow graffiti at 10:16 AM on November 10, 2011

Best answer: So I figure that when I get into the doctor's office, there is something I am doing or saying wrong, that leads me to getting sent bills for $150. What is the trick is to avoiding being charged?

If you're getting charged for the visit itself, your physician's office is probably submitting diagnosis or procedure codes that make it look like a problem-oriented visit. You should call the office and ask to talk to their billing people about how to make sure this is coded so you don't have a big out-of-pocket expenditure. If they won't work with you, find a physician that will.

My physician has informed me that my insurance pays his office less for a preventive visit, but they still code things up as preventive.

Even for a preventive visit, other procedures and tests may or may not be covered by your insurance.
posted by grouse at 10:16 AM on November 10, 2011 [1 favorite]

Response by poster: It sound like you really don't understand your insurance policy.

Yep. But thank you for all these answers, I'm reviewing it now to get a better understanding. I do have the right plan for me, but I do get sick once in a while, and it kind of sucks to pay all this money and not even be covered if I catch some flu/cold/illness.

I am fine paying for medicines or anything problem focused that arises out of my preventative-coded appointment. Thank you all for your help, I sincerely appreciate it.
posted by furious at 10:20 AM on November 10, 2011

it kind of sucks to pay all this money and not even be covered if I catch some flu/cold/illness

That's kind of the point of a high-deductible plan. Think of it more like car insurance. It covers major incidents but you're still responsible for routine maintenance costs and minor repairs. For many people that's a worthwhile tradeoff for significantly lower premiums. For each year that you don't have any major medical expenses, you should (in theory) sock away at least some of the savings in a health savings account for potential future needs.

(I'm just learning about all of this now, myself, as it's open enrollment at my workplace and I'm thinking about switching from an HMO to a high-deductible plan.)
posted by Nothlit at 11:00 AM on November 10, 2011 [1 favorite]

Here's the thing to understand about the current system of US health care: your doctor has no idea what his/her visit with you
  • Will be charged at, $ amount-wise
  • what portion you will be responsible for
  • what your copay is
  • what your deductable is.
Because your particular insurance company has a contract with his/her office for your particular plan that sets procedure prices. And those prices aren't all the same from your plan to another plan; I recently switched from my employer's Blue Cross/Blue Shield plan to my wife's Blue Cross/Blue Shield plan. And the copays and payment amounts and % responsibility is different.

So not only is there little motivation for your doc to be aware of the costs of procedures under this system but it's near impossible to know all these things anyway - odds are that few patients your doc sees that day will have identical insurance.

Which doesn't mean you can't put some pressure on the doc. Don't be afraid to raise the issue up front that you're on a high cost plan and you don't want to pay for procedures or tests with little odds of finding things, or which will find non-actionable stuff. (ie, testing for skin condition X if the treatment is just using more moisturizer/eating better) The reality is that many of your docs patients probably don't care about this so you may have to raise the issue just like you might have to remind hir that you're sensitive to vaccines that contain eggs.

Just remind yourself why you have this high deductible plan - to avoid high monthly costs whether you see the doc or not. If you think your premiums + this average annual doc visit of $X dollars adds up to more than monthly premiums for a lower deductible plan then you should look into switching. Otherwise do the same thing I do when I have to pay several hundred bucks to fix my old car - remind myself that it's cheaper, over time, than making those higher monthly payments.
posted by phearlez at 11:17 AM on November 10, 2011

It's important to remember that, in American health insurance, "covered" does not mean "paid for by the insurer". All "covered" means is that it is a cost addressed by the policy. Quite often, "covered" actually means "you will pay for this out-of-pocket and it will apply to your deductible.
posted by Thorzdad at 12:01 PM on November 10, 2011 [1 favorite]

You might also want to check out your employer's health savings account, if they offer one.

We switched plans last year (had to - hubby's office stopped offering the HMO, new plan has high deductibles), so we started socking money away in the health savings account. Any drs bills we get are paid from that account, as well as prescriptions, eyeglasses and contacts, and dental work. The money you put aside in the HSA comes out before taxes, so it lowers your overall tax bill.

The caveat is that if you put too much away and can't use it, then you lose it. But even if you put small amounts in each month, it gives you a bit of a cushion for office bills and prescriptions.
posted by hms71 at 1:05 PM on November 10, 2011

The caveat is that if you put too much away and can't use it, then you lose it.

That describes a flexible spending account, not the health savings account that would be open to a member of a high-deductible health plan. Under a health savings account, you can keep and remove the funds at any time.
posted by grouse at 1:09 PM on November 10, 2011 [2 favorites]

There are few keyword that you should look at in your insurance plan.
- deductible
- Co-pay
- Co-insurance
- Co-insurance maximum
Check and see what these amounts are.

Then check to see if a preventive care exam turns in to a regular doctor's appointment if you were diagnosed with something.
Talk about this with your insurance company and the doctor. Let the doctor know that you are there only for the free 100% paid by insurance preventive care exam. And ask them to inform you and get your approval if they are planning on doing anything that falls out of that.
That's what I do. I don't let them do any test or procedures with out discussing the costs with me.
posted by WizKid at 2:20 PM on November 10, 2011

I had UHC last year and ended up paying over $600 for my "free " annual wellness checkup. Why? Because UHC has a list of exactly what items are included in an annual checkup, including exactly which blood tests. I had requested a vitamin D Test and a thyroid test and my doctor agreed that those were good things to check, but UHC did not have them on their checklist. Despite the fact that logging onto my personal UHC website had a big splashy ad saying "ask your doctor about a vitamin D test ". Didn't matter. And they marked it as "ineligible" rather than "must be paid out of deductible " so the HSA refused to pay it and it did not count towards my deductible.
posted by CathyG at 12:25 PM on November 11, 2011

So call UHC and get a copy of the checklist and go over it with your doctor. Any other issues can be mentioned but if you want this appt to be free then ask for another appt to address those issues.
posted by CathyG at 12:27 PM on November 11, 2011

Response by poster: The follow-up - I went in to my appt, and made it all preventative. I really just sat there, answered questions, and got labwork as the doctor recommended. And yet I got billed for the lab work, which apparently was miscoded, according to my insurance company. So now I'm working it out with the lab, which I'm sure will try to screw me over. But even assuming they do fix it, it's going to take them months.
posted by furious at 5:21 PM on January 11, 2012

Response by poster: Update - they got me. Even though it was all supposed to be preventative, they ran some comprehensive blood test, and that is apparently not covered under the new healthcare regulations, and I am stuck with a bill for hundreds of dollars. I can't believe it. Even after asking this question, it still happened. I made dozens of phone calls, went into the office, conferenced the provider and my insurance, and even sent a letter. And I still have to pay, for a checkup. I am so sad right now.
posted by furious at 1:49 PM on April 19, 2012

You probably have the right to appeal for a limited period of time, but given your description, I suspect your appeal is unlikely to succeed. Here is a list of preventive services that have an A or B rating from the U.S. Preventive Services Task Force, and it doesn't look like a comprehensive blood test is on the list.
posted by grouse at 2:19 PM on April 19, 2012

If you made this an issue with your doctor's office and this still turned out this way then I think you're well within your rights to ask them to absorb some or all of the cost. It's unfortunate that they have to deal with a byzantine and insane system where none of their patients have the same coverage, but they have access to information you do not.

You can't force them to do this but you can kick up a fuss.
posted by phearlez at 5:57 PM on April 19, 2012

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