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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.
Are we talking high co-insurance costs here? I've never been on or been offered a health plan with a significant co-insurance burden although I'm aware they could hypothetically exist.
Interestingly, google-gpt says about 20% of plans have co-insurance.
So they certainly exist but aren't common.
If you are paying co-insurance charges would matter more but that dovetails into the rest of the discussion on this topic.
Outside of co-insurance - am I brain farting on anything other than: premium, deductible, co-insurance, co-pay? I guess uncovered nonsense.*
*Out of network costs are a separate problem that I forgot to mention in the other line of questioning (which is why my point is that shit is stupidly complicated!). Health systems don't really control who is and is not in network, it's usually a insurance fucking the consumer and hospital mechanism since canceling a scheduled surgery because Phil is the only anesthesia provider networked and he's off today or because the thing is emergency. This is one of the reasons why the hospital "know" they usually know what they charge, rarely know what the price is, and have zero ability to control and generally predict what the insurance company will pass along to the patient especially in uncontrolled situations like a hospital stay.
But yes thank you for reminding me of some of the other insurance related expense elements that I don't think about as they aren't in my plan, I dont think this alters the thrust of my argument though which is that the insurance is in charge of how much a patient pays and they have lots of ways to change that number away from the "price" and "charge."
I think this is a mistake on GPT's part. The majority of plans have 20% co-insurance, meaning the patient pays 20% after the deductible is met. See https://www.healthcare.gov/choose-a-plan/plans-categories/ or even just try to look for an example of a plan without co-insurance.
I asked Gemini, "Is it possible to get a Health Insurance plan without co-insurance?" and the response was:
"Yes, it is possible to find a health insurance plan without co-insurance, but they are not as common."
I followed up with, "What percentage of Americans have a health care policy without co-insurance?" and got:
I think it does matter, because it's not solely insurance deciding how much the patient pays. How the hospital codes and the choices the doctor makes regarding patient care has a direct, visible consequence on how much the patient pays. It is interesting to see that doctors might not realize that.
I can tell you that in my personal practice I try and be cost aware when possible but that a number of practical concerns come first. For one my job is to get people better, not spare their wallet, the threat of litigation makes it extremely hard to deviate from that even when both the patient and myself want to.
In some situations it appropriate (or required, most often with homeless people) to be more careful about this but I can't always do so. A classic example is inhalers, insurance change what they cover all the time, if I don't know your specific insurance plan well....it's just going to be wrong some of the time, even if I do know the insurance. Hospitals have invested in tools like e-prescribing which help with this.....but all kinds of negative effects of those things have also been generated.
One of those is that I am highly limited in what I can do. The hospital owns most physicians right now because of increased costs like EMRs we do what they say. Some times that involves practicing on our license essentially. It also frequently means things like me signing away my right to bill the hospital just does it for me based off of what I charted.
When it comes to inpatient medicine ultimately I'm going to be like "I'm sorry you are going to get a fuck off huge bill and I have no control over it and depending on your insurance that may or may not be a problem." I am also incentivized to not think about it too much to avoid burn out.
For outpatient medicine usually it's a stripped down professional fee that I have no influence over and a medication bill that I can try and save you money on.
I don't really know what percent of patients have co-insurance, and as you demonstrated and like I said I don't think about co-insurance at all most of the time. This is because legally and practically it has nothing to do with me, that's what the regulatory and legal environment have decided.
Usually when this kind of thing comes up it's "put the doctors on it" but the hospital and insurance company are in charge!
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