Think of your medical bill for an office visit as being similar to the bill you receive at a restaurant. Each service, procedure, lab, and screen is billed separately just like each menu item is billed separately at a restaurant.
When you go to your doctor for a visit, he or she is required to follow certain rules, called CPT and ICD-9 rules, for describing what happened during the visit (unless he does not accept any insurance and is paid directly by the patient for the visit). Each thing that is done during the visit has a code and each diagnosis has a code. The physician must report these codes to the insurance company in order to get paid for the work that was done. There are codes for well visits, codes for sick or problem visits, codes for each test, codes for each vaccine, and codes for each procedure. If these codes are not reported correctly, your doctor will not be paid for the visit. Many times they are reported correctly and your doctor still does not get paid correctly by the insurance company (which is generally due to a "mistake" by the insurance company). Most medical offices have one or more employees whose entire job is to report these codes and to make sure the insurance company or patient actually pays correctly for them.
At a well visit, the typical codes that are reported to the insurance company are the well visit code, codes for each vaccine, codes for the administration of each vaccine, and codes for each test or procedure (like hearing, vision, hemoglobin, lead testing, developmental screening). These codes are all linked to the diagnosis "well child". Depending on the insurance plan, some or all of these codes are "covered services" and are paid by the insurance company. Sometimes the insurance company requires the patient/parent to pay for all or part of a visit (either in the form of a co-pay, deductible, or because the insurance company doesn't cover a particular service). This depends completely on the contract between the patient/parent and the insurance company. The physician's office is required to collect from the patient/parent whatever the insurance company didn't pay.
What often causes confusion is when there is an illness or other problem that is addressed or treated at the same visit. For example, if I were to find an ear infection and treat it, I would be required to submit a code that told the insurance company I had taken care of a problem and done more than just the well visit. This is where the confusion for parents may start and here's why:
Many, if not most, insurance plans require the patient to pay for a portion of any services that are not part of the well visit. Depending on the plan, the patient may need to pay a co-pay or may pay the entire amount of the extra service if they have not met their deductible. Whether they need to pay this is determined by their insurance company, not their physician. The insurance companies have intentionally designed this system to create tension between the patient and physician, when, in reality, the insurance company has caused the need for the parent to pay the extra amount. The physician merely did her job and described the visit accurately to the insurance company.
To summarize, the physician reports the codes that describe what occurred at the visit to the insurance company. The insurance company reviews the codes and determines if the patient owes any additional fee to the physician. Whether the patient owes anything depends entirely on the patient's contract with the insurance company, not the physician.
I hope this helps clarify the issue. Please feel free to share your comments or questions.
To summarize, the physician reports the codes that describe what occurred at the visit to the insurance company. The insurance company reviews the codes and determines if the patient owes any additional fee to the physician. Whether the patient owes anything depends entirely on the patient's contract with the insurance company, not the physician.
I hope this helps clarify the issue. Please feel free to share your comments or questions.
So during the well-visit, if the physician asks, "do you have any other concerns?" an appropriate response should be, "well, that depends on whether this concern will be coded as well-child care or something else?" If for no other reason than to anticipate a deductible bill?
ReplyDeleteThat is an excellent question and this highlights the dilemma faced by both the patient and the physician. For the patient, how do I know if what I ask will fall outside the scope of the well visit? For the physician, how do I know whether this patient's insurance plan will require an additional co-pay from the patient or if they will apply the cost of the problem-oriented service to the patient's deductible? The physician's job is to report the services provided. The insurance company determines if you owe anything else.
ReplyDeleteGenerally, if the additional concern relates to a problem or illness, it will probably fall outside the well-child service and into problem-oriented service. Examples of things that fall outside well-care would be evaluation and management of infections (even viral), chronic headaches, chronic abdominal pain, or management of a chronic disease. Extended discussions or evaluation of other topics may also fall outside routine well-care.
I hope this helps. Thanks very much for your question.
Great explanation! I am always happy to pay for the health and care of my child!!! What insurance does not cover, I am happy to pay. One thing that caught me by surprise though was with vaccines and the number/amount insurance will allow in a calendar year. They only allow so many (cost wise I think) and so if the 3 month visit is in January - by the time you get to the 12 month visit those vaccines are not covered. It was no problem paying, just a surprise that I did not pay attention to. I think now there is discussion with physicians and patients/parents about spreading vaccines out a bit (while keeping within CDC guidelines) to help with the coverage of these important vaccines...I would hate to think someone would say no due to a cost issue.
ReplyDeleteThanks for your kind comment. The insurance companies unfortunately do have some products that limit the coverage of vaccines. The Vaccines for Children (VFC) program may be able to help in a situation such as yours. To qualify for VFC vaccines, though, you need to know in advance if your insurance plan will cover the vaccines. Knowing the details of your insurance plan or calling the plan and verifying vaccine coverage before each visit may help avoid such events. Thanks again for your comment.
ReplyDeleteI'm sure there are some carriers/plans that you see frequently (UGA/county-school district employees/hospital employees) such that you will anticipate how some of the services will be billed. Your staff could probably compose a menu for the top 4 plans of what is in/out of well-care services and hit at least 80% of your private insurance patients?
ReplyDeleteThat is an excellent concept. If we could count on insurance companies to play by the rules and to keep their plans the same from year-to-year, that might be possible. The problem we run into is that a single carrier will have numerous plans that may handle these situations differently. Additionally, the rules of these plans change from year to year, making it very difficult to keep an accurate list of covered vs. non-covered services. The impact on a particular patient also depends on whether the deductible has been met, which we usually do not know at the time of the visit. From experience, we receive a greater backlash from patients if we tell someone that a service is covered and it later turns out not to be.
DeleteThe agreement between the patient and physician is that the patient will pay for the services provided by the physician. The physician provides a courtesy to the patient by billing the insurance company first, instead of having the patient pay for everything at the time of service. The patient is then responsible for what the insurance company does not cover. The patient needs to understand his or her insurance policy (which is a daunting task, certainly) in order to avoid these surprises.
It should also be noted that insurance companies routinely make "mistakes" and do not pay for services that they are indeed obligated to cover. They are betting that a large number of their customers will not read their policy in enough detail to catch these "mistakes". It is a bet that has paid off for insurance companies for decades, which is why health insurance companies have made record profits in a decade that has left most other industries struggling to survive.