Someone I know (let’s call her Lisa) went to a walk-in clinic in December because she had a bad cough that wasn’t going away on its own. The nurse took her temperature and blood pressure (as they do for any patient), the doctor listened to her lungs for approximately 4 seconds, and Lisa left with two prescriptions. A pretty easy medical scenario. We’re grateful that the walk-in clinic exists a mere 30 minutes from our house, that the doctors there are reasonable and considerate, and that medications often help cure health problems. As health care goes, this was a success.
The billing, however, is the usual mess. I want the world of medical billing to be transparent, honest, fair, and comprehensible. Even if the notion that health care consumers can somehow determine the cost for health care from a provider ahead of time is terribly false, we should at least be able to figure out what we paid for after the fact.
In many apparently simple cases like this one, the facility and the doctor charge separately, so it’s impossible to see all of the charges for a single simple visit on one bill. So much for transparency. The bills are sent to the insurance company, who never verifies any of the charges with the patient. That encourages rampant overbilling. So much for transparency or honesty. The billing is done using a code system. So much for being comprehensible.
The insurer says they received two charges from the facility: one charge for $204 and one charge for $96. The charge for $96 was coded as lab work, but the insurer doesn’t know what kind. Today we received a more detailed itemization from the facility:
WIC BRIEF EST PATIENT $102
PULSE OXIMETRY FOR O2 SAT $48
WIC BRIEF EST PATIENT $102
PULSE OXIMETRY FOR O2 SAT $48
Ok, the facility double-billed us. But the obvious double-billing was hidden from the insurer because of the coding system. And pulse oximetry is not lab work, but the insurer was not told that the lab work charge was for pulse oximetry. (A pulse oximeter is the little sensor they clip onto your finger to measure your heart rate and see whether you’re getting enough oxygen into your bloodstream. You can buy one for less than $100 if you want your own. It’s hard to describe how ludicrous it is to charge separately for taking the patient’s oxygen level if you’re not also charging separately for using the thermometer or the blood pressure cuff or the stethoscope or the waiting room chairs.)
We pointed out to the insurer that the facility double-billed us, and that pulse oximetry (whether it’s $48 or $96) is not lab work. The insurer (a) has no way to verify any of this and (b) has no interest in verifying any of this. So I’ll have to ask the facility a few questions:
1. Will they fix the double-billing?
2. Will they resubmit the claim with the correct billing codes?
3. Can we save $48 next time at the walk-in clinic by bringing our own pulse oximeter?
Almost every single component of this billing system is designed to prevent the patient who actually knows what health care was provided from being able to understand or verify the charges. When it’s this hard to sort out the billing for a simple doctor’s visit, it’s impossible to sort out the billing for an actual hospital stay. Perhaps the in-pharmacy minute clinics that Massachusetts just approved will try a different billing system. They’d be hard-pressed to create a worse one.
Friday, January 11, 2008
Medical billing
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3 comments:
As someone who works in a small medical clinic, I can tell you who to blame for coding that mystifies even the well-trained medical billers at times: The AMA and Medicare. The AMA defines the codes, and Medicare decides how much these coded procedures (office visits, lab work, etc) should be paid.
Besides, I find it hard to believe that any insurance company is laxidaisical about payment. I have to argue with them on a daily basis just to get them to pay for formulary medicines for our Medicare Part D patients.
Don't blame your doctor, I assure you, he/she would rather be treating patients than filling out paperwork.
The code system is a mess, but the AMA and Medicare don’t require that it all be hidden from the patient. Two days ago, a CIGNA rep falsely told me that there was a federal law that prevented CIGNA from telling me what procedure codes a doctor had billed my insurance for on a recent visit.
Most medical offices take one of two approaches to the coding: they view it as a horrible mess that they don’t understand and just stumble through hoping that the insurer’s computer doesn’t spit it back, or they view it as an opportunity to get as much money as possible from the insurer by choosing the highest-paying combination of codes. Both of these approaches are rational responses in game theory (the first minimizing cost of learning, the second maximizing income). And under either approach, it’s also consistent to hide the coding from the patient. If you’re trying to minimize cost by not really learning the code system, you’re certainly not going to be able to talk with a patient about the coding you used on their bill. If you’re trying to maximize income by choosing the highest-paying combination of codes, you don’t want a patient interfering by pointing out the cases where the procedure codes you chose no longer reflect the actual treatment.
We are currently engaged in a class action against a provider group that bills twice for the same tests and deceptively adds a modifier to the end. If this case wins then there may be relief in your state too.
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