Getting a dr's office to change an insurance code for an office visit?
August 10, 2018 7:15 PM   Subscribe

I have an issue with a doctor's office trying to bill me more than $200 for services I paid for with a co-pay, because the billing manager won't code my office visits as office visits. What can I do to get them to change the insurance code?

I had a series of injections (Euflexxa) in my knees for osteoarthritis in January. I was told at the time that this injection has a $40 co-pay and all was good with my insurance.

No worries. I paid at each visit.

I later received a bill for over $700 for these injections, which through a process that I do not understand has been whittled down to around $228.

When I call my insurance to ask why I am being billed for services I paid for, they say that office visits with an injectible are covered with a co-pay as I was told--but my visits were not coded as an office visit. (Based only on Google, it looks to me that an office visit is a visit for treatment, which is EXACTLY what occurred. Nothing happened but the injections from a PA.)

When I call the orthopedic office with the same question, their billing person says she can't code the injections differently, as it's illegal for her to do so, as she says she doesn't know if my appointments were an office visit or not. (Am I missing something? What else could a once-weekly visit for an injection series BE?)

I'm now trying, after months of back and forth and hours of wasted time, to call the PA who actually did the injections, and ask her to tell the billing manager that my visits were office visits, so the billing manager will re-submit with office visit codes and make this $200+ balance go away.

I've called twice and left a message with the PA, and despite a message saying calls are returned the same day, she has not returned my calls.

Not only do I not make enough money to just pay $200+ to get this place to stop endlessly sending me bills for services I paid for eight months ago, is it not OK to tell a patient their co-pay covers a service, and then stick them with a large bill.

I'll continue to try to reach the PA. Should I try the actual MD next? What should I do? Is this OK for a doctor's office to do this?
posted by Jennifer S. to Health & Fitness (8 answers total) 2 users marked this as a favorite
This is a medical coding and billing question. It's quite possible the PA and the doctor won't be able to help you at all, since typically they don't know a lot about billing/medical coding. I don't do physician office coding, but the type of medical coding I do visits for an injection only aren't considered office visits and aren't coded as one. This might be what is happening here.
posted by ilovewinter at 7:33 PM on August 10, 2018

I just went through a medical billing nightmare, and the thing that finally got parties moving to assist me was, believe it or not, a one-star Yelp review. I hate that I've even typed that, but there you go. I saved over $1000 from these idiots who wouldn't respond to my phone calls/emails/mailed letters/etc.

Depending on what state you're in, you may also have some traction with your state's insurance commission. If it happens to be in CA, memail me and I'll give you some scoop on that.
posted by BlahLaLa at 7:38 PM on August 10, 2018 [1 favorite]

Your state has an insurance obud. Write an letter or email and tell the billing person that unless the practice is willing to immediately and correctly re-code your visits for the actual services rendered, you will have no choice but to file a complaint.
posted by DarlingBri at 12:58 AM on August 11, 2018 [2 favorites]

A visit to the doctors office where you talk with a doctor or PA about a problem you are having always involves about 3 things, your own complaints about the issue, the provider's findings, and the provider's medical decision making. That's how an office can code for a doctor's visit like you are describing. From what it sounds like, you're just going in for injections, which are only going to be coded as injections. Have you thought about going after your insurance company for quoting the incorrect benefits to the provider? Because it sounds like your insurance company did a misquote and it's working out in their favor, as they have to pay out less.
posted by Attackpanda at 2:34 AM on August 11, 2018 [2 favorites]

I recently had to sit through several hours of "how to succeed at billing." It was pretty dry and bean-counting-ish, but my take-away was that to be an office visit, you need "evaluation and management" documentation -- i.e. a history, physical exam, diagnosis, and management plan. The key component is really the medical decision-making, essentially, how hard did the doctor have to think about your situation.

The injection visits are probably considered procedure visits. Those get bean-counted differently, but the documentation is very different. There is no real medical decision-making, because the decision-making already happened. It sounds like this is what's going on in your situation.

You can have both an office visit and a procedure visit, but the documentation needs to show that the office visit addressed additional problems on top of whatever the injection/procedure was for. For example: someone goes to their PCP for an annual physical, mentions a wart; PCP freezes off the wart and also counsels the patient about smoking cessation, orders a cholesterol panel, refills their blood pressure meds. But unless the documentation supports that type of dual service, the billing/coding person cannot change the way the visit is coded; that would be fraud.

It's pretty crappy that they told you your insurance was good with it, when clearly they were not and you're being billed the remainder after insurance. As to what you can do about it now: you can try talking to the supervising MD (whom I assume you saw the first time?) about whether they would accept a payment plan rather than a lump sum payment, or even a write-off. If they are employed by a hospital or a large multispecialty group they might have a financial person who makes those determinations; otherwise it's up to the MD as a self-employed small business owner.
posted by basalganglia at 4:12 AM on August 11, 2018 [5 favorites]

This awakens my deep rage at the entire health care structure and their Byzantine billing practices and the mulishness of insurance companies and general frustration with the absurd levels of bureaucracy. You have done your best. You have spoken with the insurance company many times, the medical office many times. Call the medical office. Tell them you are challenging the charge because they did not properly inform you of the charges, and are not willing to work with you to resolve this issue. Send them a letter stating the same thing. You have made a payment based on their instruction. Decline to pay more.

Maybe they're charging for administering an injection and maybe your insurance puts that in a different category, who can tell? My limit is 3 calls to the insurance gnomes, 3 calls to the doc's office. If it can't be resolved with that, which usually represents a couple hours of effort on my part, I won't pay it. Your dispute of the charges can and should be given to credit agencies. People are already sick, this bureaucratic nonsense makes it even worse, and consumers should raise hell.
posted by theora55 at 2:12 PM on August 11, 2018 [1 favorite]

IT sounds like $40 is your copay for an evaluation and management service from a specialty provider. These codes would typically be 99201 through 99205 for a new patient or 99211 through 99215 for an established patient.

Then it sounds like your insurance is saying that is all that it covers and it does not cover the procedure, which would be coded something like 96372 (a code for administering the injection) and Jxxxx (a code that describes the substance injected).

If that is what they are telling you, then coding the visit as "an office visit" won't lower the charge for the injections.

SO technically you are responsible for knowing your coverage and if the docs office goofs and says something is covered when its not, its still ultimately your problem. BUT, with patient satisfaction and customer service being such a thing in healthcare these days you can make a big enough stink with the office that they didn't properly warn you of the cost and should offer a discount because you would not have gotten the service if you had be advised of the potential cost.

Sorry healthcare sucks, you have my sympathy. Also insurance companies are the most unhelpful places ever and usually the phone people there have no idea what they are talking about. You can and should ask them for a copy of the EOB, explanation of benefits, for these charges because that will have the exact codes used.
posted by WeekendJen at 12:39 PM on August 13, 2018

UPDATE on Sept. 20: I have filed a complaint with the insurance commission my policy was issued in. I also filed a complaint with my city's Better Business Bureau, as it's a billing issue and therefore something the BBB can look into.

I copied the orthopedist on both complaints.

I am a social media professional and understand the power of a complaint on Yelp or Facebook. If I have no resolution from either of these two actions, I'll use that as a last resort.
posted by Jennifer S. at 11:45 AM on September 20, 2018

« Older Ocean wedding readings   |   Anniversary Ideas, Broke with New Baby Edition Newer »
This thread is closed to new comments.