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A brief tangent on medical billing that US-based Mottizens may find useful.
So back in college I worked for an insurance company for a short amount of time. While there I received a crash course in medical billing, and what I learned ended up being pretty helpful in disputing a bill I received a few years later. All doctor's offices, hospitals, and clinics across the country (the US) use a standardized billing method. While the actual paper bill may look different, each and every one will provide you with a list of common codes for the services you received. These are called Current Procedural Terminology Codes, or CPT Codes. These codes are published by the American Medical Association (AMA) and get very, very, granular. When you receive a bill, it is to your benefit to look up these five-digit codes to make sure that they match the treatment you received. Hospitals have a perverse incentive to "upcode" your bill, that is to put down a code for a higher tier/cost, of treatment that you received. This is illegal, but it happens with shocking regularity.
Consider code 97161, "pt eval low complex 20 min." That is, a healthcare provider spent between 0 and 20 minutes in the room with the patient, providing an evaluation of a low complexity issue. An unethical hospital might "upcode" this to 97163, "pt eval high complex 45 min." Or you might have gone in for a G2251, "brief chkin, 5-10, non-e/m." That is a brief check-in for 5-10 minutes for a non-emergency issue, which might get up-coded to a 97161.
You will rarely, if ever, know the exact proper code for what you went in for. You're not supposed to. This is arcane back-end stuff the patient is not supposed to ever really understand. But the list is public information, and you can very easily check the codes you were billed against the list of treatments. Being able to respond to a bill with specific questions, such as "why was I billed for an hour-long patient interaction when the doctor was only in the room for 20 minutes?" is a very effective way of disputing a medical bill.
This is excellent information, thank you!
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There is also the converse problem -- I am friendly with a lot of doctors and they are all beyond frustrated that they will get an appointment for visit A and patients will expect them to also cover B,C,D and E. This is especially bad at the level of preventative visits turning into issue visits".
They have different approaches. Some will bill higher codes if patients want to talk about something outside the scope. Others will ask them to come back (or do a Telehealth followup). Sometimes they'll just eat it if the patient is quick about it. None of them have an objection to doing those visits, it's just that they aren't reflected in their scheduling or billing.
I expect upcoding is more of a problem than scope-creep, but I wanted to mention it because the symmetry is there.
Ask them the most ridiculous thing they couldn't get covered or documentation change they had to make to get coverage.
Should get some good stories.
Oh, I have. The interesting thing is that they are pissed they get insurance consults on patients they want to send to surgery, but they freely admit that there are some of their colleagues (and it's a "everyone knows who it is" kind of thing) that propose surgery for literally anyone that comes through the door.
Can't have nice things ...
"Good surgeons know how to operate, better ones when to operate, and the best when not to operate."
Alternatively one of the rules of The House of God - "The delivery of good medical care is to do as much nothing as possible."
Both are far harder than they sound.
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Is this "20 min" just the time the doctor is in the room with the patient, or does it include total doctor time for the appointment (including time spent looking at readings, time spent consulting with the nurses or their assistants, time spent writing up notes and doing paper work)? I've seen bills where it comes across as "30 minute appointment" even when the doctor spent 5 minutes with me, but then I do see the doctor wrote up a bunch of notes and so there clearly was time spent outside of the room with me.
I remember once being billed for a 1 hour visit with a hematologist I never saw in person - my OB consulted with them. When I asked billing they replied, "That's because you saw the hematologist." No matter what I said, they kept insisting I had an in person visit with a hematologist, even had a specific date/time I supposedly saw him (though the visit did not show up in OneChart, hmmm?.) Eventually gave up because it was "only" 200 or so after insurance and I was dealing with the other hospital billing issues of being billed by the visiting hospitalist OB in a completely different system and it going to collections before I got a whiff of the charge.
You do see this kind of behavior sometimes and it can be extremely sketchy/represent illegal behavior or it can be ".....fine" or outright "okay."
Be curious if the hematologist dropped a note on you.
Examples of each:
-A kickback program of some kind. They are rare but they still (theoretically) exist.* Typically in shady for-profit health systems. Hematologist didn't do anything useful and didn't see you.
-An annoying consult or weird consult interaction. OB asks the hematologist something. Maybe it was a stupid question, maybe it wasn't. Maybe they dropped a note on your chart maybe they didn't. Now it gets weird. Do they go see you? They might be doing coverage in another city. Did the OB say they talked to you even though they were supposed to just ask a non patient specific question? Did they actually review your chart?
Probably they reviewed your chart and provided legitimate advice but didn't want to see you because it didn't alter management or was grossly inconvenient. Now they've done something and have legal liability so the hospital will insist they bill and it is somewhat legit. Radiologist and pathologist don't come to see you.
-They did actually see you. This is most common (we inpatient at least). Stop by at 4am and make a token effort to make you up? Oh you are in the bathroom, I'll come back later? These are obviously annoying as hell as a patient but depending on the interaction it may meet standard of care (especially for consultants that may not need to see your or talk to you). I promise you whoever did this is actually doing work somewhere or otherwise engaged in fruitful activity.
Of course it could be total nonsense and someone actually scheduled an appointment accidentally.
*I've worked/trained at some places where I've had concerns but never been approached or had any actual evidence.
This is probably what happened but shouldn't there be an ICD code for that? It just seemed sketchy that they insisted I saw the Hematologist in person, as described it sounded like a office visit (this wasn't in an in-patient context, charge was a few weeks before admission for delivery). Hematologist should be paid if my OB asked a question, and I trust my OB to only ask good questions, but presumably the cost is less for a phone call vs. going into an office, paying office staff, paying for the examination room, etc?
For context I have Idiopathic Thrombocytopenia and I think my OB wanted to ask how to titrate Prednisone.
Yeah my suspicion is this is one of those weird situations where the OB legitimately needed help and wanted to make sure the hematologist got paid for their expertise. They may even have done you a solid by not making you go to a random doctor's office unnecessarily since this was OP.
What was supposed to happen was that the doctor was supposed to review your chart (probably did), see you (clearly no), and write a note (maybe?).
Not seeing you and saying they did is fraud but it's also okay sometimes. Does the delirious or sedated patient really need to see the psychiatrist to give an agitation rec? No.
Unfortunately physicians do a lot of unreimbursed work (like providing education to colleagues) and attempts to get some credit for this can be sketchy or fraudulent without actually being bad behavior.
Obviously in your case you may have appreciated the chance to ask the doc questions but most people would be excited if offered "hey let me just call this guy instead of scheduling you an extra appointment somewhere else" but it's technically not allowed.
Sometimes what we can vs cant bill for is stupid as hell (for instance: dealing with insurance!).
Since the hematologist would have accepted legal liability they def wanted to make sure they got paid and because most people's bill turn into a 20 dollar copay it doesn't get looked at closely.
Personally I think this is sketchy but fair, for those who think otherwise consider the side effects of formalizing things and reducing flexibility.
I don't know if I'm being clear but my specific and very minor gripe is that ICD has codes for everything under the sun but not a code for a physician phone consult (which would cover the time and hassle?) Or is there one and it wasn't used here?
Edit for clarity: This wasn't Out of Pocket, I had insurance. Not every insurance has a Co Pay system, even when you do have a "Co Pay" on the card you still get billed for more than the co pay later on, I've noticed this on your comments a few times over the years but you seem to have always had really good insurance and don't know what the average experience is like.
Oh yeah I see - yes we are in an area where you run into two problems "this should have a billing code and doesn't" (classic example again - insurance fuckery) and as in this case "even if this had a billing code it would be unwise to use."
If you use "low priority - don't need to see patient" billing code on someone and they have an adverse outcome you are going to get eviscerated on the stand "you could have saved her life if you just went to see her!" and going to straight to bankruptcy.
I don't know what the right solution is to this but I am pro-tort reform.
It's true that I under emphasize coinsurance and deductibles in these conversations but the deductible is going to end up used fully if anything significant happens in most insurance plans and should be considered a sunk cost when evaluating plan choices.
Ultimately using hospital pricing information if it was available would be difficult since the hospital prices interact with your insurance in unpredictable way and a lower sticker price could end up being an order of magnitude higher when comparing after insurance costs.
You are right that I need to be more active at remembering that in some of the individual situations though, even if it doesn't impact the more structural issues.
Do you mean Out of Pocket Maximum when you say deductible?
After reaching deductible the patient still pays more money the more money is spent. It is possible to reach the Out of Pocket Maximum (I did one unfortunate year). At that point they can't take any more money.
Most of the time I give birth I reach the deductible, but other considerations can make the amount I pay in addition to insurance anywhere from 2k to 6k. And these other considerations don't have much to do with how hard the birth was to manage - I always have a natural birth, 1 day hospital stay, pretty much the same experience every time. The things that change are things like an out-of-network admitting OB.
Out of Pocket maximums are going to be pretty high, like 12k even on a good plan.
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I would advise people to be extremely careful about this because the rules are frequently revised, confusing, or impenetrable to patients.
Yeah you do see issues with straight up fraudulent charges at times (usually you see this in Medicare when someone gets caught and obliterated by a federal prosecutor) but usually it's completely by the book or mild but justified up-coding. Hospitals have entire departments whose job it is to comb through notes and make sure they extract every dollar from insurance.
Does talking to the patient about their relationship count as brief therapy? What if the psychiatrist uses CBT language you aren't familiar with? Does an ear lavage count as a procedure? Does time based billing refer to purely face to face time or does coordination of care, medication ordering, and documentation count? Can you use MDM as part of your E/M instead of or in addition to time based billing? When was the last time the answers to any of these questions changed?
Doctors often go to workshops that teach them how to bill correctly, yes to up-code but also to make sure they don't accidentally commit fraud by putting something in wrong. It's hard.
If you complain you may get some stuff knocked off but it's very possible you are making an accidental fraudulent complaint and they just don't want to fight about it.
Especially if your insurance is paying, help the health system out dawg.
The doctor is unlikely to find out you did complain but if it's an iterated relationship and you keep doing this you will end up with worse service because they'll get told to clean up their documentation and be careful and it will knock them out of their flow state and likely result in petty inconveniences (ex: more likely to rely to mychart with 'schedule an appointment'").
For OP specifically - I'm obviously a homer for the medical care side of things but you should consider that insurance companies are famous for incorrectly denying things that were provided and even things were provided and billed correctly.
So, in an unexpected instance of "the system works" would this imply that the frequent flyer hypochondriac who asks the doctor dozens of follow up questions, thereby turning a 15 min consultation into a 45 minute one, will actually end up paying (either directly, or via their insurer) more?
Fuck. That. Noise. So, an army of functionaries use their best judgement to try to translate a doctor's notes into one or more of a series of codes to reconstruct the exact service provided? I thought lawyers billing me in 15 minute increments was bullshit. After the fact reconstruction of what happened layered with overly hierarchical categorization is a new level of theft.
Depending on your perspective it's either far better or worse than you imagine.
The physician's note was historically designed as a record of medical decision making on a patient and we are still primarily trained in this task. However they are now used as a record for billing, a record for legal ass covering, delivered to patients, used for cross staff communication, and as repository of information for research purposes.
As there is the greatest financial interest in doing so you more often see time and effort spent on maximizing billing but it's totally reasonable.
If I see a patient with high blood pressure I'm going to write something like "yo this patient has hypertension get some amlodipine in here stat."
Then the insurance goes oh we aren't going to pay because you didn't establish this patient has hypertension. What do you mean their blood pressure is high and its been high for 20 years and the last doctor had them on amlodipine.
Nope no hypertension.
(Billing staff: psst doc write primary hypertension)
.....Primary hypertension.
OH WHY DIDNT YOU SAY SO HERE HAVE SOME MONEY.
The classic for a long time was the Review of Systems which is sort of deprecated now but had resulted in tens of thousands of doctors being trained that if they didnt ask about renal, dermatologic and reproductive symptoms they couldn't get paid for this trauma patient whose arm fell off.
"The patient was anesthetized!!!!!" "Well just write 'patient declined to answer seven times.'"
It's not charging you for every 15 minutes of time like a lawyer its struggling to get paid for stuff we clearly did.
Yes some fraud and abused exists but essentially every physician has to be constantly thinking "what humps do I jump through to get paid for the basic standard of care thing I did."
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I mean, that's the problem. The system can be issue-based or it can be time-based. But it can't be both.
Bruh, we're at 0.1 hr (6min) increments. And I'm happy enough about it because they do good work and don't waste time. Remember you are paying a professional to deal with arbitrary issues.
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An issue that made be angry recently was that my kid's emergency room stay was upcoded from level 2 to level 4 because they wanted to take an ultrasound, which meant an extra $2k in charge, but then they charged be separately $3k for the ultrasound and $1k for the doctor's time. I asked, why is it level 4 when we weren't urgent, it took us 6 hours to be admitted? The answer is that the guidelines say that level 4 is when "more complex decision making is required" or a diagnostic test like an ultrasound is required, which is what they did. OK, but then you charged us separately for the ultrasound and the doctor's time, so you are essentially double-counting. The bot-like tier 1 billing support person did not understand this argument though, and since I already had paid the bill I had no leverage.
Your best bet when dealing with medical bills Act Like a Dot Indian. 'I'm not paying that, it is too much'. They'll knock it down eventually.
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I wrote up a response a few different ways but ultimately I couldn't write something satisfying without a lot of follow-up questions so I'll just point out that usually the reason why things are weird and complicated is because the insurance company refused to pay for something common sense so the hospital had to do some equally weird shit in response.
I didn't see anything the insurance denied. Altogether, our insurance and ourselves paid
$8,500$9k for an ER visit that involved a six hour wait in a crowded waiting room, then a brief consultation with the doctor, a catheter insertion and lab tests, and an ultrasound. The bill seems totally unreasonable to me, there is no way I can get that amount by calculating their costs from first principles. They had to be overcharging me above costs in order to pad their overall revenue.Okay so two things going on here:
The funny numbers bit. The system is designed around everyone having insurance. The numbers on a bill a not random but can essentially be thought of as random. The hospital negotiates with the insurance by saying X and the insurance says 1/4X and then the hospital says 1/2X and that's what the insurance decides to pay. It's stupid but it is the system, the numbers are funny on purpose. If you don't have insurance you get absolutely obliterated but you can usually negotiate with the hospital because they know the numbers are funny, but "you have insurance" and "this weird shit happens" is how society and government have decided to run this bullshit so that's the way it is.
The ED is for if you are dying, if you are not dying you are not supposed to be there, and it is expensive in the way that you'd expect for "this is the place where you are dying."
Unpacking this is complicated and it results in a mix of things that are the fault of various patients and things that aren't, but for the most part the ED is more expensive, complicated, and a higher level of care than actually being in the hospital. On a hospital floor things happen slowly - you might have a handful of nurses on a step down floor, your doctor might see you once at the beginning of the day. In the ED nurses have few patients, numerous types of staff you might not even think about are running around constantly (like the lady whose only job is to get people's insurance), people are in and out of your room, labs come back stat, people are constantly checking if you are dying or not. Most patients in the ED are on telemetry, most patients admitted to the hospital aren't. All these things are extremely expensive and a lot of them happen outside of patient understanding and line of sight. The ED is more like an ICU. This is part of why patients being boarded in the ED is such a catastrophe.
In any case the ED is designed such the majority of patient's are pre-triaged. You are "supposed" to go to your PCP first, or people to call your PCP's answering service. Most people used to do that while the modern model was being developed but they don't anymore. Many people use the ED as a PCP, go get obvious "wait and see" things checked out, don't use common sense, and so on. Other people can't really be blamed because they have a sensible complaint and don't triage because they aren't medical people, or because it's hard to get a PCP these days or one with a good answering service. But the system isn't designed for this. Add in other things like homeless and illegal immigrants don't or can't pay and you've got a mess.
Part of this is specifically American - in other countries people use PCP as designed more, or are more comfortable with waiting, but that isn't how we are. Step-down EDs or the equivalent have been triaged but they hard because if you fuck it up you'll get sued to hell (another American problem).
Additionally emergency care doesn't reimburse well from private or government insurance so one has an incentive to build out and staff EDs to match the volume they are getting.
The last piece is the professional fee aspect - you are paying for someone with a lot of training to figure out how safely they can do the minimum on you. Ideally we diagnose without any testing, give you the minimum of interventions, and use our brain power to rule everything that could kill you or be going wrong with your body.
Because we are on the hook if anything goes wrong! But we also don't want to give you an expensive full body scan that will give you cancer in thirty years.
NPs have much lower professional fees but they also scan and test people much more and cause more bad outcomes and unnecessary complications.
You pay ED physicians so much for them to safely do nothing, which is weird as hell but is what the ED is designed for.
In this case, there is a pre-negotiated master charge list with a million cells in by code and by insurer. There must have been negotiation in agreeing to that list, but what we paid was the list price, the insurer did not do any negotiation to lower the chargers. I think this is a newer development, I remember ten years ago or so getting bills where it would say one charge, and then have a lower "this is what your insurer negotiated." But that is not how it worked for this bill. At this point, it looks like the cash pay rates are generally lower than the insurance negotiated rates.
One of the crazy things is that for a 3mo infant this is not actually how it works. We went to our PCP first, in fact, spent almost 5 hours there before finally getting diagnosed with a UTI...and then they sent us to the ER because our PCP wanted a catheter sample and she did not feel comfortable doing that, so she said we had to go to the ER, that was the only option. Our child did not have a fever, but did have a UTI that needed antibiotics, but the only way to get those antibiotics was an ER visit. From what I have read since then, the type of antibiotics they will prescribe depends on if the UTI is deep in the kidneys, which is why they want to do an ultrasound. We could have easily gone to an urgent care facility during business hours if that was an option, but that was not an option, so instead we spent 6 hours in a packed waiting room which was a hot-box of germy kids.
If our child was on telemetry and had people checking in on him constantly that may have justified and expensive level 4 or level 5 charge, but he was not. He was clearly fine and low priority. We were just waiting hours for admission and then after that many hours for for the ultrasound so we could get the antibiotics prescription.
I didn't mean your specific situation, apologies if it came across that way.
Those numbers should still have been negotiated with some bullshit juju thought right?
Ahh shit, I meant to also blame providers in my post and may not have. Yes it's not uncommon to see someone and have them go "oh I can't handle that" and send you to the ED. A good chunk of that is absolutely to shift liability and is inappropriate but common. Biggest issue is when you say something unrelated to a specialist. Tell your endocrinologist that you checked your blood pressure at home and it was 160 over something and they'll send you to the ED even if that isn't quite appropriate. Another common problem is increasing specialization leading to specialists not knowing as much outside their field and PCPs being limited in what they can do and know (especially with midlevels). Lastly you have legitimately complicated shit, I don't really do peds at all IIRC from med school people are super fucking careful with kids that young. I think an urgent care would probably also sent you to the ED especially if ultrasound was standard of care.
Incidentally peds providers get paid way way way way way less than adult medicine.
It sounds like you were paying for hospital level of resources and in ye olden days your kid would have been admitted but now instead it can be managed conservatively outpatient - but you need inpatient level equipment (the ultrasound). One of those weird gaps.
Ultrasound is in a weird spot because it's evolving from a "nobody in the ED to can do this" to "we are starting to train everyone from day one to do this because its safe and cheap" but we are in the middle of that process. Wouldn't be shocked if in 5-10 years most PCP offices were doing it.
What drives me insane is how many of these multi-thousand-dollar fuck-ups are the result of someone not on the hook for the bill (sometimes the doctor, sometimes the patient) choosing the vastly more expensive option just because it’s slightly more convenient. This guy gets told to take his infant to the emergency room for a UTI because hey, why not? Insurance will pay for it.
You can see why insurance companies turn into money-grubbing assholes.
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What about the nurses’ time? What about the time spent in the facilities? What about liability risk? The time spent by the doctor is not the only institutional decision-makinng cost that the hospital incurred.
I'm not objecting to base charge for a level 2 emergency room visit ($700) which should have covered the facilities and the nurse time (which was very little). I'm objecting that they upcoded that to a $2400 charge while then itemizing and also charging for the things that supposedly triggered the upcoding (the doctor's time and the ultrasound).
It doesn’t seem obviously retarded to me to have both a per-patient complexity-weighted administrative charge, and also a per procedure/per doctor-hour charge. Invoices for complex professional services are incredibly dense like this in many industries.
Pretty normal to essentially charge for "doctor - seeing you, thinking about you, and documenting you" and "things doctor did to you."
However in this case you could alternatively summarize it as "random blender of shit put together in an attempt to get the insurance company to pay enough for the hospital to stay afloat."
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I haven't seen your details, but the complex issue could be the ED physician and the extra doctor's time was probably the radiologist. It's not double counting.
Just looked over my bills. We got itemized $600 for the radiologist, $800 for the emergency room doc. Then on top of that was the $3,300 for the ultrasound itself. Then on top of that was the up-coding of the ER visit from level 2 (which would have been $700) to level 4 which was $2,400. And then there was also another $900 for catheter insertion and $940 for labs. Everything feels over charged ($900 for a two minute catheter insertion..?) but it particularly galls me that they up-coded me from 2 to 4 because of the ultrasound and decision making and then charged us separately for those things.
Yup. I mean, it’s bad alright.
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