Friday, March 14, 2008

Has this happened to you?

In October of 2007 I scheduled a routine ladies annual exam. I had also been having some headaches, which I was fairly certain were due to poor posture at the microscope and computer and/or eye strain. I planned to talk to the doctor about these headaches since I knew it would come up in the interview anyway.

My insurance company pays for one 'preventative care' exam each year. When I called to schedule my appointment I was very careful to use that language. I said I wanted to schedule a preventive care exam. The person scheduling asked me if there was anything else I wanted to talk to the doctor about. I said I had been having some headaches.

When I got there and filled out the intake form, I put 'preventative care exam' and 'headaches' under primary reason for visit. I don't recall a 'secondary reason for visit' or 'other things to discuss' section of this form. No one at the clinic mentioned anything about how to fill out the form.

My visit went well. It was my first visit at this clinic, the doctor did a long history and spent a significant amount of time on the review of systems questionnaire. Then we walked about my headaches. She prescribed some therapeutic massage and an eye exam, after which we finished the normal part of the yearly exam. I was there for less than an hour and the doctor was very attentive and knowledgeable.

In November I got the first of the forms from the insurance company. I recognized right away that my visit had not been billed as a preventive care exam. I called the Insurance company. They said they cover the visit according to the codes that come in.... ok, that made sense.

I called the Physicians group (they were the ones who had billed the insurance first) and told them my preventative care exam had not been billed as such. They said they would call the billing clinic to look into the billing codes and I would get a letter or an updated bill.

In December, I got the rest of the forms from the insurance company also indicating that the clinic had billed me for an office visit, not a preventative care exam. I also got another bill from the Physicians group that my bill would be going to collections if not paid within the next 30 days. Ok. I clearly needed to take care of this myself.

I called the Clinic and said I had been billed incorrectly. Preventative care exams are covered at 100% and do not count towards my deductible. I was being charged over $200 for this visit which included paying for a significant portion of the lab work for my pap smear.

I am told I need to submit an online form if I want them to review the billing codes for the visit. However, I am still responsible for payment while they review it. Ok, that is fine.... it sort of provides an incentive for them NOT to 'find' anything that needs to be changed as it would mean extra paperwork on something already paid.... but that is the process. Ok.

In February, I get a letter back explaining that after reviewing my records, my appointment had been billed appropriately and to bill it any other way would be misconduct or illegal. What!?

First of all..Why? What was in my records that doesn't say I scheduled and had a preventive care exam? And... what is going on? I am the one being charged for a visit that should have been covered by my insurance, and now its been suggested that *I* am trying to get them to do something unethical? What the heck?

The actual office I needed to talk to had never returned my calls. So I called the same office at a different branch of the same hospital...hoping that branch would motivate someone to call and tell me what the heck was going on. The person at that office said he tells patients to call in the morning, right when the office opens. "You are more likely to reach someone the end of the day they are burnt out and usually don't answer the phone." Ah....

I call in the AM, and a nice lady answers. I am relieved at 'Hello'. She says she is actually just talking to someone about my case right now and can she call me back. Uh oh. I practically beg her to please, please, please call me back because I have had such a hard talk reaching anyone to TALK to about what is happening. She does call me back and she is very nice.

She tells me that basically because my doctor and I discussed headaches during my visit (she does not mention
the intake form at all) that they can no longer bill it as a preventative care exam. And, she says, in the future, to ensure that I am billed as I expected, I should not discuss any other ailment with my doctor during that visit that is not directly related to the women's health exams. I should instead, bring it up at the end of my visit and schedule another visit. Hm.

Ok...because we talked about headaches for a significant portion of the visit, the office "cannot" bill the visit as preventative care exam. Interesting. Then she thanks ME, saying she wasn't aware of this policy either.

I am a bit least I have an answer to what happened and I talked to someone who was patient and understanding....but whole policy didn't sit well.

Since when is discussing chronic ongoing problems at a preventive care exam no longer considered part of preventive care? I have been going to the doctor on my own for 20 years and I have had discussions about many things..some of which resulted in prescriptions or physical therapy, but all were billed as yearly preventative care exams... this had never come up before. In fact, it hadn't come up 1.5 years earlier at the clinic across the hall either.

So, I decide. What do I want out of this? Its wrong to have the billing of an appointment change with no warning. Moreover, its wrong to have to worry about what one can and cannot talk to your doctor about. And its wrong to have schedule a separate visit to talk about over-all health. I decide that what I want is for the physicians to know how these billing practices are affecting patients.

So I write an email to the attending physician of the resident that I had seen. I state in my letter that my care was excellent. I say that billing this way seems to border on unethical. And I am clear that my intent is to simply bring this matter to the attention of the doctor.

I get a nice email back. It was a simple explanation: how I filled out the paperwork (the intake form primary reason for visit section had two complaints) had changed the focus of the visit which in turn changed the way it was billed. Ok. I understand...but that does not address that we talked about something the doctor would have asked me about anyway and is considered part of preventative care to discuss. How did the clinic decide that this visit billing should be changed?

In the reply, the attending physician said he had decided to change the billing code to a preventative care exam. However, he decides to change the billing code because no one communicated to me how the billing changed because of 1) how I filled out the intake form and 2) time that was spent discussing headaches with the doctor.

In my email, I did not ask for a change in the billing code. And he did not decide to change the billing code for any of the reasons I would have hoped. I feel like two things are wrong here.

1) That clinic appears to be looking for opportunities to justify billing patients for a more expensive visit. Because I filled out the intake form with two reasons for the visit, and we spent a significant amount of time addressing the headaches and since my insurance won't allow the clinic to bill for two visits in one day... they billed my visit based off the more expensive office visit. Doesn't this seem like the clinic is taking advantage of my insurance company? And, no, the clinic didn't inform me regarding how the bill would not be what I expected... but that is secondary to taking advantage of the insurance company.

2) The doctor and the clinic did not decide that discussing ongoing conditions is, indeed, part of preventative care. Nor did they decide that discussing a condition that would come up on the systems review interview is, truly, preventative care. They have developed a system where everything discussed in the office with your doctor is classified separately .... so it can be billed separately.

He decided the clinic should have told me that if I wanted to talk to my doctor about headaches, I would need to schedule another visit or allow the billing to change for my annual ladies exam. This is where he felt they went wrong.

I believe in paying for medical services. My health is important enough to me that I am willing to pay for it. And I am not suggesting that physicians not bill for services provided... but the focus has clearly changed. When billing and more billing is the becomes secondary. Patient/doctor relationships become secondary. And preventive health becomes secondary.

I also understand that insurance through my employer is NOT a free lunch. I pay for that benefit with lower salary. Bottom line: I pay my insurance. And while I have had some run-ins with insurance companies in years past...this is the first time, I am left feeling like I not only need to watch out for my being taken advantage of by the insurance company, but I also need to watch out for my insurance company being over charged.

Overall, my feeling regarding this affair is acute disappointment. However, I will be sure to schedule a separate visit if I want to discuss that with my doctor.


sageweb said...

Wow that is crazy. I have never heard of anything like that. I go in to the doctor with multiple problems all the time. Never had a billing issue. I go in with asthma and get a pap smear...lucky me.

Lachlan said...

Having worked in the healthcare industry, I am totally unsurprised by this. And I am most upset, as you are, by the doctor's response/shift in focus.

We have a very dysfunctional, horrible system in some ways. My Dad quit practicing medicine because of the insurance system... as a single practitioner, it was too much hassle and he felt he could no longer serve his patients.

Now in addition to medical learning, our doctors are being educated about how to maximize billing and market themselves.

Wrong. Just wrong.

Syd said...

Does your state have an Insurance Commissioner? Trust me, that will jerk a knot their chain, if you can get somebody's attention in the Commissioner's office.

Jen said...

Sageweb - I had never had an issue regarding multiple things discussed either. Times are changing.

Lach - My pop works in ER and despite also having to do more paperwork in the current medical climate, he has the luxury of never having to turn people away. He is also a proponent (as am I) of some sort of socialized medical program.

Syd - Insurance commissioner! Thanks for the tip!

Lachlan said...

I forgot your dad was an ER doc.

Yes, Syd's right- and we do have a very responsive insurance commissioner here in WA. Air our your complaint- it's worth it!

The Recovering Straight Girl said...

I had my girlie exam today AND I talked about all kinds of other things. Uh oh.

Despondency said...

When a patient comes into the office for a routine preventive examination and also has a significant new complaint (e.g., chest pain or irregular bleeding) or a new or established chronic condition (e.g., hypertension or type-II diabetes), the visit becomes a combination of preventive and problem-oriented care. When a problem is documented and distinct from the documentation of the preventive service, CPT guidelines recommend submitting a preventive medicine services code (99381-99397) for the routine exam and the appropriate office visit code (99201-99215) with modifier -25, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service,” attached to the problem-oriented service. It’s important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between preventive and problem-oriented services.