Might my PCP be ripping off Medicaid?
February 29, 2020 11:36 AM Subscribe
...and if so, is it worth researching/reporting? I am on my state's health insurance, which is pretty much a fancy name for Medicaid, and recently had an appointment for a "complete physical" with my PCP. But that appointment was no different from my regular check-ups. I'm wondering if by terming it "complete physical" she is charging the State for services not rendered?
During the many years when I had private health insurance I traditionally would receive monthly or quarterly statements in the mail which detailed all of my doctor visits and treatments, etc, and what was billed to (and paid for by) insurance and what (if any) balance I had to pay. Even back then I remember noting with surprise that a cortisone shot in my hip joint I'd received from my rheumatologist during an office visit had been billed as "out-patient surgery". (?!) Maybe it was just a terminology "thing", but I was surprised to see a mention of "surgery" on my statement.
Fast forward to last week, when I had an appointment with my PCP (one of the few in my area who accepts Medicaid) for what was termed a "complete physical." Back in November 2019 at the conclusion of my regular "check-up" the doctor told me that I was overdue for a complete physical and that I should schedule one soon. Which is what I did as I "checked out"....and as the date drew near I was dreading the appointment - "complete physical" meaning in my mind stipping down and wearing a paper gown and getting a pelvic exam and such. As it turns out, the Complete Physical was no different than any other appointment - I didn't remove any clothing other than my winter coat. Doctor discussed my current meds and gave me a recommendation slip for a mammogram (for whatever place I found on my own). She didn't look into my ears or in my mouth/down my throat. She took my blood pressure (not my temperature) and listened to my heart/lungs through my clothing. And that was that. I was done in just under 15 minutes.
I can't say I wasn't pleased at not having to place my feet in stirrups, but on the other hand, it made me wonder why this particular appointment was constantly referred to by the persons at the appointment/check out desks as a "Complete Physical"? I do not receive any sort of receipt or cost breakdown from the PCP's office or Medicaid, but I have a funny feeling that the doctor's office might be charging the State for things the doctor did not do. And if that is the case (that her office gets more money for charging for a complete physical versus a check-up-type exam), is it worth contacting the Medicaid folks? I'm sure that, like most Government offices, they're overworked and understaffed, so would my inquiry make any difference?
During the many years when I had private health insurance I traditionally would receive monthly or quarterly statements in the mail which detailed all of my doctor visits and treatments, etc, and what was billed to (and paid for by) insurance and what (if any) balance I had to pay. Even back then I remember noting with surprise that a cortisone shot in my hip joint I'd received from my rheumatologist during an office visit had been billed as "out-patient surgery". (?!) Maybe it was just a terminology "thing", but I was surprised to see a mention of "surgery" on my statement.
Fast forward to last week, when I had an appointment with my PCP (one of the few in my area who accepts Medicaid) for what was termed a "complete physical." Back in November 2019 at the conclusion of my regular "check-up" the doctor told me that I was overdue for a complete physical and that I should schedule one soon. Which is what I did as I "checked out"....and as the date drew near I was dreading the appointment - "complete physical" meaning in my mind stipping down and wearing a paper gown and getting a pelvic exam and such. As it turns out, the Complete Physical was no different than any other appointment - I didn't remove any clothing other than my winter coat. Doctor discussed my current meds and gave me a recommendation slip for a mammogram (for whatever place I found on my own). She didn't look into my ears or in my mouth/down my throat. She took my blood pressure (not my temperature) and listened to my heart/lungs through my clothing. And that was that. I was done in just under 15 minutes.
I can't say I wasn't pleased at not having to place my feet in stirrups, but on the other hand, it made me wonder why this particular appointment was constantly referred to by the persons at the appointment/check out desks as a "Complete Physical"? I do not receive any sort of receipt or cost breakdown from the PCP's office or Medicaid, but I have a funny feeling that the doctor's office might be charging the State for things the doctor did not do. And if that is the case (that her office gets more money for charging for a complete physical versus a check-up-type exam), is it worth contacting the Medicaid folks? I'm sure that, like most Government offices, they're overworked and understaffed, so would my inquiry make any difference?
There can be a lot of weird insurance rules so you may be right, but also maybe not. Just to give you some examples I've experienced as a patient and as someone working in a physicians office:
I had a private insurance that required that I, as a new patient, have an annual physical appointment much like what you described before I could have my pelvic exam appointment. The appointments couldn't even be on the same day. I had to take two mornings off work at a new job just to get my BC prescription renewed (I'm still pissed off about that).
I also used to help out with a newborn hearing screening program. In that particular state (at least at that time), Medicaid wouldn't pay for newborn hearing screenings, but wouldn't pay for anything related to a delivery if a hearing screening was not performed (or maybe at least attempted, my memory is a little fuzzy).
Physicians (and their billing departments) also aren't infallible. I worked at a clinic that had a patient dispute a claim because a code had been used for out patient surgery when it was an office visit. Turned out, whoever set up the billing system didn't make the full description of the billing code visible, so the provider thought they had billed for X procedure, but had actually billed for a similar but more intense service. The clinic corrected the patient's bill and their billing system (I think they went back and corrected several bills).
This isn't to say your suspicions are wrong, but it's hard to tell. They could be intentionally or mistakenly mis-billing, or be doing exactly what's needed.
posted by ghost phoneme at 12:15 PM on February 29, 2020
I had a private insurance that required that I, as a new patient, have an annual physical appointment much like what you described before I could have my pelvic exam appointment. The appointments couldn't even be on the same day. I had to take two mornings off work at a new job just to get my BC prescription renewed (I'm still pissed off about that).
I also used to help out with a newborn hearing screening program. In that particular state (at least at that time), Medicaid wouldn't pay for newborn hearing screenings, but wouldn't pay for anything related to a delivery if a hearing screening was not performed (or maybe at least attempted, my memory is a little fuzzy).
Physicians (and their billing departments) also aren't infallible. I worked at a clinic that had a patient dispute a claim because a code had been used for out patient surgery when it was an office visit. Turned out, whoever set up the billing system didn't make the full description of the billing code visible, so the provider thought they had billed for X procedure, but had actually billed for a similar but more intense service. The clinic corrected the patient's bill and their billing system (I think they went back and corrected several bills).
This isn't to say your suspicions are wrong, but it's hard to tell. They could be intentionally or mistakenly mis-billing, or be doing exactly what's needed.
posted by ghost phoneme at 12:15 PM on February 29, 2020
Are your 'routine check ups' are for a particular health condition? If so, this is called technically "Office or other outpatient visit for the evaluation and management of an established patient." They will bill this differently than what Medicare (and presumably some kinds of Medicaid) call 'Annual Wellness Visits." or Preventative Medicine Visits (not Medicare) . If you take any sort of routine medication - say, cholesterol medication - the visits to make sure your condition is billed as Level 1-5 Office Visit (depending on complexity). A visit to go over wellness and general health questions is a probably an annual wellness visit/preventative visit, or equivalent, which is billed another way, which I suspect is what your PCP called a 'complete physical'.
Fraud is committed if they bill for a 'level of service' higher than what they provided. So I tick a box at the visit saying, on a scale of 1-5, how complicated your visit was; there are specific things I need to meet and write down to get the a Level 5 visit versus a 1 or 2.
An 'annual wellness visit' is billed completely differently. (Pretend, instead of '1-5', I just ticked 'B'.) The rules for this are, to me, surprisingly light-weight on thinking and a lot of making sure we all know what we're supposed to do. It's things like making sure history is up to date, that you get any additional screenings or referrals you might need, and you're up to date with age/bio-sex appropriate screenings. The recommendation for the mammogram suggests this. A lot of the things for billing this visit are done during the visit by other folks (eg, measuring weight) or by reviewing information before. For example, you may have reviewed a list with your current meds - and the provider can likely see in an electronic chart system a report from your pharmacy saying your refills are up to date. Some of the most general stuff is assessed by talking to you normally - like, I can tell if I need to do a formal cognitive screen - and the measurements required by Medicare are only weight and blood pressure.
I am not your medical provider and I work in a specialty, not primary care, department, but I just updated my clinic note template to include some of these things to make my billing department happy. There are also a lot of tickboxes to say I reviewed certain things. All this lets me do this faster, because I'm given 20-25 min to see folks and charting shouldn't be the rest of my day. Medical billing is a goddamn minefield and providers are audited; when I get audits, it's usually saying 'you could have billed more.'
posted by cobaltnine at 1:21 PM on February 29, 2020 [5 favorites]
Fraud is committed if they bill for a 'level of service' higher than what they provided. So I tick a box at the visit saying, on a scale of 1-5, how complicated your visit was; there are specific things I need to meet and write down to get the a Level 5 visit versus a 1 or 2.
An 'annual wellness visit' is billed completely differently. (Pretend, instead of '1-5', I just ticked 'B'.) The rules for this are, to me, surprisingly light-weight on thinking and a lot of making sure we all know what we're supposed to do. It's things like making sure history is up to date, that you get any additional screenings or referrals you might need, and you're up to date with age/bio-sex appropriate screenings. The recommendation for the mammogram suggests this. A lot of the things for billing this visit are done during the visit by other folks (eg, measuring weight) or by reviewing information before. For example, you may have reviewed a list with your current meds - and the provider can likely see in an electronic chart system a report from your pharmacy saying your refills are up to date. Some of the most general stuff is assessed by talking to you normally - like, I can tell if I need to do a formal cognitive screen - and the measurements required by Medicare are only weight and blood pressure.
I am not your medical provider and I work in a specialty, not primary care, department, but I just updated my clinic note template to include some of these things to make my billing department happy. There are also a lot of tickboxes to say I reviewed certain things. All this lets me do this faster, because I'm given 20-25 min to see folks and charting shouldn't be the rest of my day. Medical billing is a goddamn minefield and providers are audited; when I get audits, it's usually saying 'you could have billed more.'
posted by cobaltnine at 1:21 PM on February 29, 2020 [5 favorites]
I just had my annual physical last Monday. I'm a guy. BP, pulse, blood oxygen, and temperature were all done by the medical assistant. My doctor looked into my eyes, ears, and throat. He listened to my breathing front and back. He listened to the arteries in my neck and he also listened to my digestive system with the stethoscope. He manually checked my thyroid and lymph nodes. He would normally order a CBC and CMP with lipids, and also do an ECG but I had just had all of those done two weeks before by my cardiologist. He also reviewed my medicines. I'm almost 60, so he would have done a digital prostate exam if I didn't have a urologist that had done it within the last year. I do this every February.
posted by Grumpy old geek at 3:16 PM on February 29, 2020
posted by Grumpy old geek at 3:16 PM on February 29, 2020
Just as a data point, my complete physicals have always looked like yours and things like pelvic exams have always either been separate or "add ons" when the doc would see I was due. Without more info, I wouldn't think your doctor did anything improper.
posted by ldthomps at 4:02 PM on February 29, 2020
posted by ldthomps at 4:02 PM on February 29, 2020
A pelvic exam is not part of a normal primary care visit for women, in my experience. Some primary care physicians may offer a “well woman” exam that includes a pelvic exam/breast check/Pap smear but most leave that to ob/gyns. You should still be able to get a statement or explanation of benefits from your Medicaid plan and see what was billed for this visit. It’s possible your Medicaid plan incentivizes your PCP to give you a yearly wellness visit vs. a regular visit, as explained by cobaltnine above.
posted by MadamM at 4:41 PM on February 29, 2020
posted by MadamM at 4:41 PM on February 29, 2020
Accusations of Medicaid fraud can ruin a medical professional's life, so you should probably be careful in your accusations. Did one person, maybe the front office staff, say something about this being a complete physical? It could have been a flip comment, and be nothing more than that. Instead, I would look for a pattern before you file a grievance.
posted by eleslie at 6:50 AM on March 1, 2020
posted by eleslie at 6:50 AM on March 1, 2020
No this is not fraud. Cobaltnine has it. Your checkups are billed as "sick" visits, which is the colloquial term for "Office or other outpatient visit for the evaluation and management of an established patient". You also get one "well" visit per year which is this complete physical to basically touch base and make sure all the health info your pcp has is up to date. For someone who regularly sees their pcp to manage some condition, these visits feel similar to the patient. For a patient that maybe touches base with their pcp once a year but sees other specialists for whatever, the wellness visits are a little more useful and distinguished from the one time they pop in for a sinus infection.
Also as far as the outpatient surgery billing, that is based on how the provider is credentialed and where you got the service (stand alone office, surgical center, hospital based practice, etc) so thats not fraudulent either, just a quirk of the dumb billing games.
posted by WeekendJen at 7:06 AM on March 1, 2020
Also as far as the outpatient surgery billing, that is based on how the provider is credentialed and where you got the service (stand alone office, surgical center, hospital based practice, etc) so thats not fraudulent either, just a quirk of the dumb billing games.
posted by WeekendJen at 7:06 AM on March 1, 2020
Medicaid is very state dependent, but in general there's no such thing as a billing code for a "complete physical." The wellness exam or preventive exam is probably what she meant, and as described above this can be very light on physical exam and lab work other than recommended screening labs like cholesterol panels. It's more about making sure you are getting your recommended cancer screening, immunizations, and so on. I don't like calling them "physicals" because people expect a ton of lab work and a really detailed physical exam which may or may not be appropriate, but lots of doctors who were practicing before the Affordable Care Act will still call them that.
For non-Medicare patients with chronic conditions that I'm seeing several times a year, my preventive care exams often look a lot like my regular exams because I try to address preventive care as it's due rather than at a once a year visit (because my Medicaid patients can sometimes fall in and out of care and I try to seize the moment, and because my visits are a little longer than what's standard for many offices). But other physicians have different workflows and scheduling systems. Medicare has some visit-specific requirements for an Annual Wellness Visit like cognitive screenings and functional assessment that require extra time, but still don't involve a very detailed physical exam.
posted by The Elusive Architeuthis at 10:09 AM on March 1, 2020 [1 favorite]
For non-Medicare patients with chronic conditions that I'm seeing several times a year, my preventive care exams often look a lot like my regular exams because I try to address preventive care as it's due rather than at a once a year visit (because my Medicaid patients can sometimes fall in and out of care and I try to seize the moment, and because my visits are a little longer than what's standard for many offices). But other physicians have different workflows and scheduling systems. Medicare has some visit-specific requirements for an Annual Wellness Visit like cognitive screenings and functional assessment that require extra time, but still don't involve a very detailed physical exam.
posted by The Elusive Architeuthis at 10:09 AM on March 1, 2020 [1 favorite]
I don't know about Medicaid, but I think you got an inadequate physical. Breast exam, discussion of depression, diet, smoking. They should check to see if you're due for a cholesterol screen, blood sugar screen, bone density, colonoscopy. Vision and hearing should be reviewed. You could make an anonymous call to the local Medicaid office and ask them.
posted by theora55 at 12:29 PM on March 1, 2020 [1 favorite]
posted by theora55 at 12:29 PM on March 1, 2020 [1 favorite]
Response by poster: Accusations of Medicaid fraud can ruin a medical professional's life, so you should probably be careful in your accusations. Did one person, maybe the front office staff, say something about this being a complete physical? It could have been a flip comment, and be nothing more than that. Instead, I would look for a pattern before you file a grievance.
I understand that, which is why I posed the question. The person scheduling this "complete physical" appointment very specifically phrased it as such when I made the appointment last year. The PCP also had told me after my routine "check-up" last year that I needed to schedule a complete physical. That phraseology was used many times, which is why I was surprised that the "complete physical" appointment was no different than my previous check-ups.
I'd like to add, however, that back when I first started seeing this PCP, I was still covered by Blue Cross (but a very basic version, with a limited amount of participating physicians). Back in those days, my check-up appointments involved me disrobing from the waist up so she could check for(I guess) moles and unusual lesions, she had me lie down and examined my breasts. She also looked into my ears and in my mouth. That was just a "check-up" appointment. So I presumed that a "complete physical" would involve at least that much, but apparently with the change of insurance coverage, not so much.
(Some back story: I was dx'd with Lupus (SLE) back in 1989 and as the years went on some collateral conditions such as Raynaud's Syndrome and Antiphospholipid Antibody Syndrome. The rheumatologist I'd been seeing for the past six years does not accept Medicaid, and I've been relying on PCP to refill my various prescriptions until I can find a rheumy in my area that accepts it. But PCP seems to dismiss anything I say....I mentioned at one point that I have poor circulation. She asked "What makes you say that?" "I have Raynaud's Syndrome," I began to explain. "Unless your hands turn red, then white, then blue, you do not have Raynaud's Syndrome." I didn't get a chance to tell her about my C-Reactive Protein and Sed Rate numbers from the last time I'd seen my rheumy. She told me that we had 15 minutes for this appointment and I was wasting time by "arguing".)
posted by Oriole Adams at 1:08 PM on March 1, 2020 [1 favorite]
I understand that, which is why I posed the question. The person scheduling this "complete physical" appointment very specifically phrased it as such when I made the appointment last year. The PCP also had told me after my routine "check-up" last year that I needed to schedule a complete physical. That phraseology was used many times, which is why I was surprised that the "complete physical" appointment was no different than my previous check-ups.
I'd like to add, however, that back when I first started seeing this PCP, I was still covered by Blue Cross (but a very basic version, with a limited amount of participating physicians). Back in those days, my check-up appointments involved me disrobing from the waist up so she could check for(I guess) moles and unusual lesions, she had me lie down and examined my breasts. She also looked into my ears and in my mouth. That was just a "check-up" appointment. So I presumed that a "complete physical" would involve at least that much, but apparently with the change of insurance coverage, not so much.
(Some back story: I was dx'd with Lupus (SLE) back in 1989 and as the years went on some collateral conditions such as Raynaud's Syndrome and Antiphospholipid Antibody Syndrome. The rheumatologist I'd been seeing for the past six years does not accept Medicaid, and I've been relying on PCP to refill my various prescriptions until I can find a rheumy in my area that accepts it. But PCP seems to dismiss anything I say....I mentioned at one point that I have poor circulation. She asked "What makes you say that?" "I have Raynaud's Syndrome," I began to explain. "Unless your hands turn red, then white, then blue, you do not have Raynaud's Syndrome." I didn't get a chance to tell her about my C-Reactive Protein and Sed Rate numbers from the last time I'd seen my rheumy. She told me that we had 15 minutes for this appointment and I was wasting time by "arguing".)
posted by Oriole Adams at 1:08 PM on March 1, 2020 [1 favorite]
Your doctor is a piece of work.
Not even gynecologists recommenced yearly pelvic exams any longer. Jen Gunter’s book talks about how stream lining well woman care has better outcomes. A lot of doctors put no stock in a clinical breast exam, either— they say to just get the mammogram. Physicals are different now that technology has surpassed our senses.
posted by sweltering at 9:36 PM on March 1, 2020 [1 favorite]
Not even gynecologists recommenced yearly pelvic exams any longer. Jen Gunter’s book talks about how stream lining well woman care has better outcomes. A lot of doctors put no stock in a clinical breast exam, either— they say to just get the mammogram. Physicals are different now that technology has surpassed our senses.
posted by sweltering at 9:36 PM on March 1, 2020 [1 favorite]
Response by poster: Dunno if anyone is still reading this, but just a few days ago I suffered a syncope (as dx'd by ER personnel)....apparently I'd fainted while standing up from the chair in my home office. All I know is that I was getting up at one moment - no feelings of dizziness or anything - and the next thing I knew my husband was at my side (he'd heard my body "thump" on the floor from downstairs) asking if I was OK. I was lying on the floor with no memory as to how I'd gotten there. Husband then said "Your eye is all red, I'm taking you to the ER!" I didn't understand what he meant until I looked into a mirror on my way out the door - I'd apparently smacked my face on the edge of my desk as I fell. My left eye was swelling at an alarming rate.
At the ER I was seen very quickly and given the usual preliminary tests before they rolled me into a CT scan machine. I'd fractured a bone in my face. They wanted to admit me in order to find out why I'd fainted, but during this pandemic I really didn't want to spend any more time in a hospital. Plus with my Medicaid-type insurance I didn't know what expenses I was already racking up...
Anyway, one of my points in relating this story is that I had a similar episode late last year - I'd been working at my desk and apparently had been rising to my feet when the next thing I knew my husband was squatting down while I was on the floor, asking me if I was OK. Luckily I hadn't hit anything that time. I mentioned this incident to my PCP during my next scheduled appointment (about a week later), and she said "Sounds like a middle ear thing". Didn't even pull out her otoscope or ask any further details. Again, when I began explaining that I hadn't felt any dizziness prior, she dismissed me and continued with her traditional 15-minute exam.
So that's why I wonder.....how much is she charging the State for this very perfunctory treatment?
posted by Oriole Adams at 2:07 PM on April 20, 2020
At the ER I was seen very quickly and given the usual preliminary tests before they rolled me into a CT scan machine. I'd fractured a bone in my face. They wanted to admit me in order to find out why I'd fainted, but during this pandemic I really didn't want to spend any more time in a hospital. Plus with my Medicaid-type insurance I didn't know what expenses I was already racking up...
Anyway, one of my points in relating this story is that I had a similar episode late last year - I'd been working at my desk and apparently had been rising to my feet when the next thing I knew my husband was squatting down while I was on the floor, asking me if I was OK. Luckily I hadn't hit anything that time. I mentioned this incident to my PCP during my next scheduled appointment (about a week later), and she said "Sounds like a middle ear thing". Didn't even pull out her otoscope or ask any further details. Again, when I began explaining that I hadn't felt any dizziness prior, she dismissed me and continued with her traditional 15-minute exam.
So that's why I wonder.....how much is she charging the State for this very perfunctory treatment?
posted by Oriole Adams at 2:07 PM on April 20, 2020
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posted by Oriole Adams at 11:37 AM on February 29, 2020