Medical Billing Question
August 16, 2016 10:17 AM   Subscribe

I met with a physician's assistant at a medical practice for a consultation. We had a conversation that lasted less than 15 minutes. They are billing for a one hour consultation. When I inquired they explained "this is what we always do". Sounds fishy to me, but what do I know? I am wondering if this is standard / acceptable practice.

The bill reads as follows:
Office consultation, 60 minutes $432
Insurance adjustment: ($256)
Total Due: $176

Over and above the 15 minute consultation, I probably sat in the exam room waiting for the PA for about five or ten minutes.

I am not covered by insurance for this visit because it was under my deductible. I did speak with a claims person at the insurance company, and she said that I should call the physician's office, that it is probably an error.

The billing person at the physician's office said "this is our standard procedure". I responded by saying that the PA went from the consultation with me to another patient, and possible another before the hour was out. I asked if it is appropriate to charge for two or three hours for one hour of a PA's time.

The billing person said she would run my question by her supervisor. She never got back to me. A few weeks after that I received a statement which says that my account is seriously past due.

If this is standard and acceptable practice in the context of American medicine then I will promptly remit payment. In some ways it will be easier for me to write the check and forget about it. I do not want to tilt at windmills. However, the double / triple or quadruple billing seems, on the surface, unsavory. So I would appreciate some perspective.
posted by elf27 to Health & Fitness (20 answers total) 2 users marked this as a favorite
 
I can't speak for doctors because I'm in canada, but here, this is would be very standard practice for some professions. For instance, if you talk to a lawyer on the phone for 5 minutes, you'll probably be billed for an hour.

Your medical office you went to might have a minimum 1 hour for billing, and I wouldn't find that too unusual. It's something to ask about in the future before you go.

(recently I had a dental hygenist who charged a minimum of 3 units of scaling, even if you didn't use that many. Crazy. I switched.)
posted by euphoria066 at 10:26 AM on August 16, 2016


It may be that there are procedure codes that have a time element associated with it (e.g., consultation - 50 minutes). If that's the case, they should bill for the appropriate code, the one that says 15 minutes.

Otherwise we would call that fraud, as they are likely double and/or triple billing. If it was me, I would call someone in the office with authority and tell them that, regardless of their standard practices, you believe the claim is fraudulent. That you'll be happy to pay for the services that were rendered, but that you plan on reporting it if they insist that it be paid as is.
posted by jasper411 at 10:43 AM on August 16, 2016 [1 favorite]


If it was your first visit with this person, and/or you discussed something specific that requires specialty knowledge - i.e., it wasn't something basic like a sick visit for cold symptoms, they are more likely to bill that as a complex office visit. In the medical offices I've worked in, the content of the visit is as important for billing codes as the time spent.

It's always worth calling to tell them you only spent 15 minutes with the practitioner and asking if they can recode it as a simple visit. But I don't think what they're doing here is particularly unusual or egregious. I mean, not any more egregious than anything else about our health care system.
posted by something something at 10:43 AM on August 16, 2016


They just bill in one-hour increments. People don't care because insurance companies pay it. Insurance companies don't care because they have their excuses (such as this) for high premiums. The medical field loves it because they are in bed with the insurance companies. And the cycle continues...

(As far as the lawyer comment, they usually bill in 3-, 6-, 12-minute increments. Tracking time can be quite tedious if you bill for time, such as a paralegal or lawyer. A lawyer's office better not be billing in one-hour increments, or they can't do anything for the rest of that hour since they are not allowed to double-bill.)
posted by TinWhistle at 10:45 AM on August 16, 2016 [1 favorite]


Do you have five-digit procedure codes associated with this bill? They should be either on the bill itself or on your explanation of benefits from your insurer. (Your insurer should still be billed even if you have to pay the deductible. That's the only way they know you're paying your deductible.)
posted by grouse at 10:57 AM on August 16, 2016


The term you are looking for is upcoding which is fraud. They need to bill the correct code. Document the time you spent with the PA and then call your insurance company. Even though they aren't paying the bill, they are likely to follow up.
posted by 26.2 at 11:05 AM on August 16, 2016 [8 favorites]


I think you should call the insurance company and ask them about this, and here's why:

This is, in a real and legal way, covered by your insurance company. Not only did they negotiate the rate (which you related above), but they are going to end up paying more money if you use your entire deductible and incur more expenses.

It may well be that the physician's assistant only needed 15 minutes to correctly diagnose you or order a test, but in the unlikely event that the visit was too rushed and an incorrect treatment results, then the insurance company would also be involved in any further expenses you incur to correct the mistake.

The insurance company has a further interest in this since they are paying claims by other people who are using this practice or other similar practices.

Also, a lot of the money you are paying to the insurance company -- and that I am paying to the insurance company, so I care too -- is paying lawyers, administrators, and other professional people whose job it is to research, set policies, communicate with doctors and patients, and answer questions like this.

So, please call the insurance company and ask about this. They probably want to help you. This is exactly the sort of thing they should know about.

I would love it if you'd follow up here and fill us in on what they say.
posted by amtho at 11:27 AM on August 16, 2016 [3 favorites]


Time is not the only factor by which we bill. Complexity also matters. When we bill we bill by the complexity of the issue and evaluation, if the complexity isn't apparent by history and physical exam then we need to denote time spend in the visit. This is standard practice and makes sense; an experienced practitioner will need the same amount of time to make he diagnosis and perform the counseling.
posted by noonday at 11:48 AM on August 16, 2016 [1 favorite]


CPT outpatient billing codes give times, but they're more like suggested/average times; billing those codes doesn't require that the provider spend that exact amount of time with a patient. A "high-complexity" new patient would have the same 60-minute code, regardless of how long the appointment actually was. That said, it's a little hard to believe that you were a "high-complexity" patient if you only required 15 minutes of care.

As others have suggested, I would contact your insurance again. (Because you are covered by insurance for this visit, you just have 100% of the payment responsibility.)
posted by lazuli at 11:50 AM on August 16, 2016 [7 favorites]


Ditto noonday; the exact number of minutes is not the only factor taken into account when billing E&Ms.
posted by ThePinkSuperhero at 11:51 AM on August 16, 2016


Dr. Noonday said: "Time is not the only factor by which we bill. Complexity also matters. When we bill we bill by the complexity of the issue and evaluation, if the complexity isn't apparent by history and physical exam then we need to denote time spend in the visit."

That's absolutely legitimate. Charge whatever fee is appropriate.

But the bill said "1 hour" when the visit was not 1 hour, or even close. Your reasonable comment about charging for complexity doesn't justify the OP's issue -- the bill gave a wrong description of what actually took place.
posted by JimN2TAW at 12:31 PM on August 16, 2016 [1 favorite]


As was previously noted above the length of time is sometimes used as a marker for how complex a case is, generally most office visits fall between level 3 to level 5. Some physicians bill every visit as a level 5; this has come under increased scrutiny and rarely flies these days.

Frequently specialists are successful in billing a < 5 minute visit as a level 5 given their extensive level of training and aggressive documentation that is expanded upon by dictation software and advanced practice nurses that do all the paperwork prior to you being seen.

Visits typically can range from "I just moved here and need my birth control refilled" I'd say that was a level 2, which is probably a 5-10 minute visit. Most office visits like diabetes (foot exam, tinker with blood pressure and diabetes medications, order some surveillance lab) fall in the level 3 range. That can easily be boosted into a level 4 visit with aggressive documentation for the same amount of time, 15-20 minutes. Level 5 visits are honestly typical of most of my patients on medicaid, they have probably 4+ unrelated medical issues in addition to a slew of poverty sequelae, chronic pain, several motor vehicle accidents and various traumas, osteoarthritis from a lifetime of manual labor, in addition to the standard American general issue diabetes mellitus and hypertension; except theirs is typically poorly controlled as their insurance mysteriously drops a few times a year so they aren't always taking their medications... and their job security is minimal; it doesn't allow them to take an entire day off to drive four hours to the city and wait in the lobby for another three hours in order to see me on anything approaching a routine basis.

I was under the impression that a physician extender such as a physician assistant or nurse practitioner could only bill up to level 3; unless this was a specialist visit and whatever the PA did is being directly reviewed by the physician prior to a follow up visit, it seems like this falls under the gray area of medical billing.

I have worked in offices where we were highly encouraged to overbill and let the patient / insurance company push back. I find this distasteful and routinely underbilled and underdocumented as much as possible in order to help my fairly impoverished patient population out; but this frequently caused more problems than it helped.

This is the sort of shit that causes me to greatly value hospitalist work, referrals go through immediately, someone else has to deal with the billing, and social workers can take care of the thousands of loose ends that exist in this America of patchwork medical care and victim-blaming.

Ultimately this touches on the three thousand issues on why I hate working in clinics because so much of the metrics impacting the quality of my delivered care is completely outside of my control.
posted by hobo gitano de queretaro at 1:25 PM on August 16, 2016 [7 favorites]


Response by poster: Do you have five-digit procedure codes associated with this bill?
Yes, coded as 99244

When we bill we bill by the complexity of the issue and evaluation
I had already seen my primary on this condition, but I wanted to see a specialist to confirm the advice I had been given. The PA listened and confirmed the primary's advice. This is why I referred to the visit as a conversation. There was no examination, simply verbal back and forth.
posted by elf27 at 1:25 PM on August 16, 2016


Yeah, keep in mind the clinician spends time outside the room on your care - documenting, asking colleagues, looking stuff up, etc, and, as mentioned above, these time increments are not meant to be exact, but sounds like they may consistently be up-billing as there is also a code for a shorter visit they could use instead.

I wouldn't go straight to the insurance company unless you really want to piss this medical practice off. I would start by calling and asking to speak to a manager and explaining your concern. They may be willing to re-bill.
posted by latkes at 1:26 PM on August 16, 2016 [3 favorites]


Hmm... I could be wrong but the specialist may always bill for an hour as they tend to need more time, and on average this may be generally the time they take, in which case I would say your reaction is not really necessary.
posted by latkes at 1:27 PM on August 16, 2016


Yes, coded as 99244

You can read about it here. It certainly seems they are upcoding if they are using this code all of the time regardless of complexity of service. You didn't even see an internist.
posted by JackFlash at 1:41 PM on August 16, 2016


This is how the AMA describes 99244 (requires free registration):
Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
Note a comprehensive examination is required for use of this code. Sounds like you did not receive an examination at all so use of this code may be fraudulent. You may want to report this to your insurance company again in writing (and note that they said it is their practice to always bill this code even when there is no examination). You may also send a letter to your physician assistant and anyone who supervises that office stating that you regard this bill as fraudulent, that you have reported it to your insurance and that you will report it to state licensing agencies if your bill is not corrected within 7 days.
posted by grouse at 1:45 PM on August 16, 2016 [7 favorites]


A 99244 is a level 4 office consult.

To meet the level 4 criteria. It would need to meeting either all three care criteria: comprehensive exam, comprehensive history and moderate complexity decisions or meet the 60 minute time line.

Both the history and exam need to be Comprehensive (the ranking is Problem Focused, Expanded Problem Focused, Detailed and Comprehensive).

Here is one decision tool for care providers.
posted by 26.2 at 1:46 PM on August 16, 2016 [2 favorites]


Ps complaining about this is likely to get you fired by the office. You'll get a letter stating you have 30 days to change practices. I've been on your side of it and been "fired" by two practices mid-pregnancy.
posted by tilde at 2:59 PM on August 16, 2016 [1 favorite]


Unfortunately, a provider can bill a level 4 with a 'comprehensive exam' without touching a person. hobo gitano de queretaro described what is often done best.

Check this article for more details: "How To Get All The 99214s You Deserve"
Exam. The requirements for the detailed exam are a little more difficult to remember. In part, this is because a detailed exam can be defined in more than one way. It can be either an examination of at least five organ systems/body areas (according to the 1995 version of the documentation guidelines) or the performance and documentation of at least 12 specific exam findings (according to the 1997 version).2 In most circumstances, it is easier to use the first definition since it requires documentation of less detailed information. You frequently perform this level of exam when managing patients with multiple chronic conditions.

Here’s an example of a detailed exam involving a common complaint: a patient presenting with a fever, cough and chest discomfort. It might be documented as follows:

Vitals: temperature 101.5, BP 140/80;
ENT: negative;
Neck: supple;
Chest: rales in both bases, pain on deep inspiration;
CV: negative;
Abd: benign.


In this exam, the provider does touch the patient, but here's another example:
General: No diaphoresis, well appearing.
HEENT: Normocephalic, atraumatic.
Eyes: No conjunctival injection, no icterus.
Neck: Supple.
Chest/Lungs: No respiratory distress.
CV: Normal heart rate (can be reviewed on vital signs)
Skin: No visualized rashes.
Neuro: Alert and oriented x3
Psych: Normal mood/affect, normal behavior

That example includes 9 organ systems that can be assessed without touching the patient (potentially qualifies for highest level of complexity, level 5 billing). Depending on the content of your discussion, a level 4 might not be supported, but I would suspect based on the limited information we have here that this would not actually qualify as fraud.

I'd recommend just negotiating with the office for a lower fee based on the fact that you're self paying, rather than based on a concern about fraudulent coding. I don't work in an outpatient office but from I hear that is a common strategy that can reduce your payment.
posted by treehorn+bunny at 6:58 PM on August 17, 2016 [3 favorites]


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