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JLP’s Thumb Saga Continues…

By JLP | January 29, 2010

As I wrote yesterday, I cut my thumb on December 22, 2009. I went to the minor care center, which is an EXTENSION of the hospital’s own emergency room—it’s just in a different location. I know, because I called the hospital and they told me so. When I arrived at the minor care center, I noticed a sign posted on the window that read something like, “Christus Minor Care Center will bill this visit as an emergency room visit…”

Under my Aetna plan, emergency room visits are covered no matter the location. In fact, the Minor Care Center’s portion of the bill has been paid in full and is taken care of. The Minor Care Center billed it as an emergency room visit and coded it as such and Aetna gave them no problems.

The doctor, however, is a different story…

For some reason, the doctor billed my visit as an office visit. Under that coding, Aetna will not pay the bill. Aetna told me to call the physician’s billing department and have them resubmit the bill and then they (Aetna) will pay it.

So, I called the billing company. THEY REFUSE TO CHANGE THE BILL! The woman told me that they got tired of trying to work with insurance companies because some would want it billed one way and others would want it billed another way. So, she said they researched it and figured out that it was against the law for a physician to bill something as an ER visit if it was at a minor care facility. So I informed her that the minor care facility is AN EXTENSION of the hospital’s ER and she said, “But it has to be physically-attached to the hospital in order for it to be considered a part of the hospital’s ER.”

WOW! I was stunned and was getting angry. So I asked her, “What if the minor care facility is on the same campus as the hospital but not physically-attached to the hospital?” She said it would still not be considered a part of the ER.

What’s even more mind-boggling is the letterhead for the physician’s bill reads: Jefferson EMERGENCY Medical Associates!

Now, was this woman feeding me a line of bs? I don’t know. I just can’t understand why they don’t want to do what necessary to get paid because I can tell you right now: I’M NOT PAYING THAT BILL! I have insurance and the insurance company is willing to pay as long as they receive the correct bill.

I tried calling the physician but his office is already closed for the weekend. Aetna did at least tell me that I can file an appeal with them if the doctor’s billing company refuses to work with me. We’ll see how that goes.

Topics: Miscellaneous | 33 Comments »


33 Responses to “JLP’s Thumb Saga Continues…”

  1. BG Says:
    January 29th, 2010 at 4:41 pm

    “The woman told me that they got tired of trying to work with insurance companies because some would want it billed one way and others would want it billed another way.”

    That is medicalease for: “we are trying to extract as much money from you as possible”. If they code the bill correctly (or at least in the way that would make you and Aetna happy), they will probably only get $100 from you and Aetna together. Leaving it coded the way it is, they are trying to get an additional $668 from you. They have no incentive to help you here.

    I wouldn’t be surprised if they coded it that way specifically because they realized you were ‘out-of-network’, or saw the loophole giving them a chance to be blood-sucking bastards.

    Your best bet is to work with Aetna, and see if they can give you some options. Either way, I agree you shouldn’t pay that bill. Worst case it goes into collections and stays on your credit report (big deal, everyone has medical crap in collections).

  2. Ron Says:
    January 29th, 2010 at 5:09 pm

    Sounds like the office staff is just lazy to me. Their pocketbook isn’t on the line. I might remind the doctor of the old line — “Better a fast nickel than a slow dime.”

  3. Dennis Says:
    January 29th, 2010 at 5:40 pm

    The company that I work for has a compant in which we can call for help like this. They have the resources at hand to work with both parties.

  4. Retiredat40 Says:
    January 29th, 2010 at 5:45 pm

    Insurance these days is a scam. I’ve had the same type of problems getting an annual Rx. You have to know how to get your doctor to code the visit. And then if you do that right, they send your blood tests to a lab not covered and you have to pay the whole bill at marked up prices that would have been 100% covered.

    These things are supposed to make us smart consumers of healthcare.

    When we get the sad story about how insurance companies will be put out ofbusiness if we have health care reform, I say BRING IT ON. I will dance on their graves!!

  5. Greg Says:
    January 29th, 2010 at 6:51 pm

    Hey Jeff, if it comes down to it and you have to pay the bill yourself then I suggest paying them as slowly as possible. I know that in Texas as long as you are paying them $10 a month they can do nothing to you. So if it was me then I would pay them slowly, very, very slowly.

  6. BG Says:
    January 29th, 2010 at 7:25 pm

    #4 Retired@40) Hmm, in this case, I think the insurance company is in the clear. The immoral people are the billing company associated with that doctor.

    That line about the office must be physically attached to a hospital is pure BS — absolute horse sh*t. Also, looking at the first page of the companies website:

    http://www.christushospital.org/services_minor.html

    has in bold letters:

    ALL MAJOR INSURANCE IS ACCEPTED.

    I assure you that Aetna is a very major insurer in TX.

  7. Dreamer Says:
    January 29th, 2010 at 7:52 pm

    You know what would have fixed all this? A tax break. They fix everything.

  8. 7racer Says:
    January 29th, 2010 at 8:11 pm

    to Greg #5.

    I hope you are not serious. You do realize that as of today, medical care is a service industry. You are not guaranteed free service. As a physician in Texas can you show me where it is stated in law that paying $10 a month prevents me from sending you to collections?

    Most of the time, we allow patients a payment plan to help in anyway possible to make payments.

    When you get a repair on your car, are the kind of person that refuses to pay for it or just pays for it penny’s at a time? Where do people come off thinking everything in medicine should be free? The cost has to come from somewhere. Expect it from copays, premiums, or taxes in a public plan.

  9. Steve Braun Says:
    January 29th, 2010 at 8:14 pm

    JLP – Send the bill to Obama and don’t give it another thought. He’ll take care of it by inviting the doctor and an Aetna representative to the white house for a chat over beer. Everything will be cool after that. You can stake a Nobel Peace Prize on it.

  10. BG Says:
    January 29th, 2010 at 8:17 pm

    #8) In Texas, if you are getting a repair on your car, the mechanic is required to obtain your signature approving of the repairs, and that paper is to include the estimation of the charges.

    As a doctor in Texas, I’d love for you to defend why doctors are not required to obtain a signature before putting stitches on someones thumb?

    Hell, Jiffy Lube is regulated better than your profession, sir.

  11. 7racer Says:
    January 29th, 2010 at 8:24 pm

    JLP,

    just to demonstrate the confusion. I operate in the hospital, but as outpatient surgery. The surgery happens in the hospital. On the same premises and sometimes with the same nurses as the “inpatient” cases. Yet my surgeries are classified and billed as outpatient, where as the guy 10ft away from me in the other OR is billed as inpatient.

    Even though the physician is an “ER” doc, he might be functioning as a doctor doing an “office visit”. And the facility, more like a “walk in clinic”. That is, your condition is more of an urgency (non life threatening) and thus does not require emergency room service.

    With that said, the facility should be coding the same thing, that is emergency visit, as well as the doctor. If the facility coded it as a office visit, that is basically what you did. You had a walk in office visit. Does that make sense?

    Just because the facility is attached, or the doctor’s group is named “Emergency” has no bearing to how that facility is set up.

    Cost wise to the insurer, it is cheaper to have office care vs emergency visits.

  12. 7racer Says:
    January 29th, 2010 at 8:27 pm

    reply #10.

    BG, it is HEAVY regulated. AND the costs are all spelled out for you. You get it when you sign for your insurance statement. It has nothing to do with us doctors. It depends on the plan you sign. In the plan YOU SIGN UP FOR, your cost, doctor choices, deductibles, etc….are all spelled out.

    AS A CONSUMER, it’s up to you to follow your plan.

  13. BG Says:
    January 29th, 2010 at 8:42 pm

    #12 7racer) What? You are saying that my Aetna policy says that the going rate for thumb stitches is $776? A 15-minute job at most? I assure you it says that _nowhere_.

    My father is a doctor too, and both he and I despise scumbags like JLP went to. I hope you are able to sleep well at night knowing that you are screwing people out of their hard earned money by charging exorbitant rates for simple ‘procedures’.

    And this bait-n-switch maneuver that this doctor is pulling should be out-right illegal. How dare you (or this doctor) claim to accept ALL MAJOR INSURANCE, and then after the visit, claim that you are out-of-network.

    My original claim still stands: JiffyLube is regulated more than your profession. My CAR gets better treatment than a PERSON.

  14. BG Says:
    January 29th, 2010 at 9:05 pm

    JLP) A little more perspective: my wife’s gall-bladder removal surgery (outpatient) last month cost $3,920 (insurance + patient payments). That covered the hospital services, surgeon, anesthesiologist, etc.

    So, apparently five thumb-stitch ‘procedures’ by this one doctor is equivalent to a single incision laparoscopic surgery in a hospital OpRoom under general anesthesia to remove a gallbladder. Oh, that also includes the pathology on the gallbladder, post surgery. And also includes the two-week later post-op visit with the surgeon.

    You, my friend, are being screwed.

  15. 7racer Says:
    January 29th, 2010 at 10:09 pm

    BG are you arguing what the “value” of medical care is worth to you? That is what you think the “cost” of the physician services is worth? That is a bypass surgery should be worth X dollars and spinal surgery worth Z?

    or

    what is spelled out in a contract to your insurance carrier?

    This is point that I am trying to state to you. That is. The cost are determined in the contract that the physician signs with the insurance carrier. The reason your wife’s GB surgery was the cost you see it is because that is what your carrier negotiated with the physicians it agreed to pay in the contract as the “cost” of the procedure.

    I am stating that the cost are know to you upfront. If the physician or facility is out of network, then you would be responsible for the fee (again clearly stated in your insurance contract)

    Physician’s are either contracted to an insurance. For an exam we bill X, a procedure Z etc…

    What I was stating, is that the facility, like the example I gave of my operating IN THE MAIN OPERATING ROOM of an INPATIENT hospital, can be classified as outpatient. This facility, maybe considered an “office facility”. There is no BAIT AND SWITCH GOING ON.

    In regards to signing forms for procedure. That is present too. It’s called an ABN, this started mainly with medicare that stated some services may not be covered under your plan but your doctor is recommending this treatment. You can elected to not receive the treatment and try something else, or you can sign ABN knowing that you might be charged for the service. We now make all patient’s sign this form in case services may not be covered, regardless of insurance type.

    Your father should know this.

    I do not know why you are directing hostilities or suggesting that doctors or myself are some kind of charlatans.

    What I was trying to show was how this might be considered as an office facility even though it is part of the hospital and staffed by ER physicians. Similar to how I operate as an outpatient in an inpatient facility.

    And how dare you suggest that I am doing something immoral that keeps me sleeping well at night. I can show you my accounts where I have given away >$60,000 in free care and services in the last 6 months. A physician partner returned from Haiti to do charitable work. You are right, because he is not sleeping well at night due to one of our office nurses that traveled with him dying in the earthquake from her charitable sacrifice.

    Also, it makes little financial sense for physicians to bill patients. We know we won’t collect it. Just look at emergency rooms where the payment rate is 50%. Plus, if we don’t get the payments, it is usually not worth our time and money to try to extract it out of you (adding to healthcare cost to someone else BTW). Our only other choice is to contract this to a collection agency. That is agreeing to pay them a percentage of the collections (it can’t be more than the fee of the service). So why it the world would we want to go thru all of that and get less money then just billing the insurance and getting a full payment?!?!

  16. BG Says:
    January 29th, 2010 at 11:00 pm

    #15 7racer) sorry for my crude remarks. And am terribly sorry to hear about your colleagues loss, especially while during charity work — that is an absolute tragedy.

    But, from my point of view, as a simple consumer. When we go to a hospital (like in JLP’s case), and are told that the place takes our insurance, we feel protected and in the good hands of doctors we trust. The absolute last thing that comes to our minds is that we may be completely screwed over by what I call ‘abusive’ billing practices.

    From a patients POV, if a doctor is roaming around in a clinic, and that clinic is known to accept Aetna, and yet that doctor does not accept Aetna — then they are predators! Our insurance company negotiates common-sense rates for all doctors that are in our network, and any that are out of our network can charge whatever they want. There is no ‘contracted rate’ when we are out-of-network, or just simply uninsured — and I’m sure you know this.

    If we are unlucky enough to end up being seen by a doctor, that we don’t get to pick, and that doesn’t accept our insurance then we are royally screwed. I would open to accept that if the insurance didn’t pay a penny, and I had to pay 100% of the cost out of pocket, that would be fine. But when the doctor finds out that he is not obliged by a ‘negotiated rate’, he invariably charges 5 to 10 times more for the exact same care!

    It is this type of abusive billing for people that are either ‘out-of-network’ or just plain uninsured that rubs me wrong. Perhaps if doctors would simply charge common-sense rates, then they wouldn’t have so many things go into collections.

    I bet you that if JLP was only charged $200 for his stitches, he’d pay it right now, out of pocket. But that doctor charging $776 because he is ‘out-of-network’, and knowing that he’d never get that amount if he were ‘in-network’ is highway robbery.

    And maybe you don’t know as a doctor, people with insurance do see what you bill, and we also see what you end up receiving. Can you explain to me why my wife’s surgery was billed over $15,000, yet also agreed to the contracted rate of just under $4,000? If we were out-of-network, or just uninsured, we’d pay an extra $11,000 for what? What value are you providing for that extra $11,000?

  17. BG Says:
    January 29th, 2010 at 11:16 pm

    7race) one other thing. My 73-year old father charges the Medicare negotiated rate, period. Doesn’t matter if you are on Medicare, have some other kind of insurance, no insurance at all, whatever — simply the Medicare negotiated rate.

    Perhaps you could try this in your practice, and maybe us consumers would be happy with the costs of services your are providing…

  18. Harm Says:
    January 30th, 2010 at 3:31 am

    Insurance or no insurance, I wonder why they
    are charging you more than $100 to sew up your
    thumb. I respect doctors, very much, but this is
    simply out of line, imho, and one big reason
    health care in the U.S. is in such trouble. I have
    a policy with a $2500.00 deductible, and if I thought it was going to cost me $1000.00 to put
    5 stitches in my thumb, I probably wouldn’t have it
    done….if it gets infected, then maybe I’ll go
    to a doctor and at least get my money’s worth :P

  19. 7racer Says:
    January 30th, 2010 at 4:25 pm

    BG,

    I understand your frustration. In the medical field we see it all the time since we are on the “front line”. Why do you think hospitals and medical practices have to hire huge billing and coding departments just to keep all of these rules straight? What one insurance might cover, the other might not.

    I have this same problem when I operate in the hospital. I sometimes get the problem that a patient’s insurance covers my surgery and the hospital facility BUT does not cover the anesthesiologist. The anesthesiologist submits his bill only later to find out that the patient wasn’t covered. The billing department/or contracted agency does their job and submits the claim. From the consumer perspective this seems crazy and many don’t understand why they aren’t covered. But that is just how the system sometimes works. That is there are a bunch of physician and physician practices that are contracted to many insurance carrier as well as patient’s with many plans.

    I can give you another crazy example. Sometimes, we hire a new young physician or an older one from another city/state. When they join our practice, they are not automatically on each plan that all of the regular partners are. You have to apply to get on the plan. Sometimes, insurances places a limit and will not allow any other physicians on the plan during that calendar year thus having to reapply later. Again for the consumer it seems crazy, as you can come into a group practice to see physician X and find out they are not covered and have to see physician Y.

    This in fact happens in our practice where 2 of my partners see preemies and are part of Texas medicaid where the rest of the group are not. If both take a vacation during the same time and one of their patients come in to see us as an emergency, they would get billed as seeing a physician out of network, even though every time prior to that, insurance covered the full cost.

    As you can see, this is SUPER common and has to do with how the financial/business side of medicine runs. There isn’t anything predatory going on. There is no bait and switch. No collusion.

    In regards to medicare rates and private pay rates. The financial dynamics are such that medicare rates are known….especially to private carriers. So when physicians and physician groups go to renegotiate their contract, the private carrier have a huge advantage of knowing what the “cheapest rate is in the area (the medicare rate)”. **also note that the rate is different from state to state, for example an office visit might pay more in California vs Montana due to cost of living etc..**
    With that advantage, the insurance company knows what it wants to reasonable pay out as a contract to the doctors. What is consider a great contract to a private carrier is 120% of medicare rates. We don’t get that all the time. So think about that. Medicare, doesn’t have to negotiate with doctors, they just decide that they are going to pay X for this office visit or Y for this procedure. That’s it. They can even pay us BELOW what it cost to do the procedure and we have no recourse. The private carriers see what medicare charges and negotiates a rate 10-20% above that. THAT’S IT!

    So if some things get re-imbursed at a loss, we try and hope that medicare keeps certain payments fair to cover the loss….using a higher pay item to offset the loss of a lower one over a large group. So you hope that some higher paying private insurance payments help offset the lower paying ones based on economies of scale. I can give you an example where we don’t even bill for a drug that we inject because the cost to do the billing is greater than the cost of the drug, that is we lose more money if we don’t even charge for it!

    Finally, for those that do not have insurance or are out of network, billing companies/offices don’t have a magic button that’s labeled “drain them dry”. You are right that there isn’t any limit that we can charge. But we don’t go around thinking hey this guy with no insurance came in with a nice cell phone and lexus and is no pay, I’m going to charge them 100x medicare! Woohoo! Most of the time you are long gone by the time billing comes to me and asks what I want to charge. In that, like any billing office system, there usually is just the standard rate and discount rate. There isn’t any other choice in the billing.

    and to 18) Harm. Typically, for a new patient office visit, the charge is around $300 for a medicare rate. Add to that procedure fees which could equal that same amount so say 600 total. Which isn’t that far off form the quoted bill (though the rates are different for the specialty (I’m a subspecialist and that is around the cost for a new patient visit).

  20. 7racer Says:
    January 30th, 2010 at 6:02 pm

    “And maybe you don’t know as a doctor, people with insurance do see what you bill, and we also see what you end up receiving. Can you explain to me why my wife’s surgery was billed over $15,000, yet also agreed to the contracted rate of just under $4,000? If we were out-of-network, or just uninsured, we’d pay an extra $11,000 for what? What value are you providing for that extra $11,000?
    BG Says:
    January 29th, 2010 at 11:16 pm
    7race) one other thing. My 73-year old father charges the Medicare negotiated rate, period. Doesn’t matter if you are on Medicare, have some other kind of insurance, no insurance at all, whatever — simply the Medicare negotiated rate.
    Perhaps you could try this in your practice, and maybe us consumers would be happy with the costs of services your are providing…”

    BG, I just wanted to address this last question separately. I am also a consumer too remember. Of course we know that patient’s see the bill. I can totally explain why you are billed over $15,000 and are contracted $4000. Again, this is the business and accounting side of medicine. When physicians goto insurance companies we start our negotiating with a higher price then negotiate from there. Think about it like your strategy for selling a car, I say it’s worth $20,000 but you state $10k and you go from there. It’s just the way medicine is billed and the accounting is done. On my last months practice billing statement, my collections is 50% less then my billing. Try to think of any other business that it’s like this.

    In regards to simply charging medicare rate, that is up to the physicians. I typically do if you are indigent. One of my partners won’t. He will offer a payment plan. His common justification for this is that some people won’t argue a $30 a month cell phone plan, but will if this is a payment plan for a medical visit.

    Plus, if you want a flat, universal medicare negotiated rate for everything, make sure you are happy with what you are asking. Because that type of system is seen in national health care systems like Canada and the UK. They work….I just want you to realize your choices and what you are asking for.

  21. Jamie Says:
    February 1st, 2010 at 9:47 am

    this is not an insurance company issue. it is the doctor’s issue. The billing departments do NOT like to do one extra thing to help. Call back and say, “May I speak to your supervisor please?” If you get the same line from the superviser, say, “May I speak to YOUR supervisor please?” and keep doing that until you are talking to a VP who sees the futility of spending so much time talking to you and the benefits of doing what you ask. But be polite. Be firm. Be diligent. Your insurance company may help you, but they really have no power over your doctor’s office or his billing office. You are the customer.

  22. BG Says:
    February 1st, 2010 at 11:29 am

    #20 Jamie) The supervisor in the end is the doctor himself.

    #19 7racer) I understand what you are saying. You are correctly claiming that when someone is out-of-network (or uninsured) then they do not have the negotiating power of someone who is properly covered by their insurance company.

    Since an ‘out-of-network’ person has no negotiating power (in your mind), you can charge whatever you think the services should cost, without taking into consideration what the patient thinks the services should cost — and also completely disregarding what you would’ve been paid had you been an ‘in-network’ doctor (pick any insurance company). This is very one-sided, there is no negotiating on the costs here, which ends up with the consumer being screwed.

    Back to your car example, you are saying that I _must_ pay $20k for the car, even though I think it is worth $10k — non-negotiable, and saying this after the fact (after services have already been rendered).

    But, you are missing the key part of our (consumer) negotiations: we just simply refuse to pay your bill. This is probably the #1 reason why you have stuff in collections. As #2ron beautifully said: “better a fast nickel, than a slow dime”…

    The question to ask yourself is: from all the charges you have in collections on your patients, would you make more money (or have less losses in your mind) if you called up those patients and ask them if they would just pay the ‘Medicare-negotiated rate’, or just simply accept their insurance negotiated rates as if you were in their network?

  23. Don Says:
    February 1st, 2010 at 12:51 pm

    I’ve never lost in a billing dispute, and I suggest you go to the billing office at the clinic and talk to a real person.

    You need the billing people to be on your side in my experience. You want them to see you as a reasonable person who is trying to get this bill paid (and not as someone likely to stiff them).

    They need to understand that you are firm about not paying the bill until it has been properly discounted by your insurance company and applied to your deductible/coinsurance, but when the ducks are in a row this account will be made whole. This interaction should pit you and the clinic against the insurance company, not you against the world.

    This is so important, that I always work with the same billing person at the local hospital, and in fact I sometimes drop by and say hello and commiserate with her (because dealing with insurance is a miserable job) even when I don’t have any open accounts. These are the people who can keep your insurance claims in the loop and prevent them from going to collections.

    If you piss off the billing folks and they send your bill to collections it becomes much harder to get the bill resolved. The hospital has sold your bill (for pennies on the dollar maybe) so they don’t want to waste time helping you, and the collections people often can’t work with you by law; they just collect. You absolutely don’t want you bill to go to collections because you need the clinic to help you get this resolved.

    The other thing you need to do is write to the insurance company and appeal the claim (not just call). Your letter should be courteous. It should state the facts about your claim, instruct the insurance company that they have made an error, and that they need to re-evaluate the claim, discount it, and pay it. You need to do this in writing and you may have only 30 days to do it technically.

    I would also mention to the billing agents (who you are going to talk to in person right?) that you have written an appeal letter and that you need their help getting this resolved. It tells them that you are actively trying to get their bill paid, and that you aren’t just a deadbeat.

    If it is denied again, your second letter should be stronger. Each letter should escalate in frustration. You would want a judge or arbiter to get angry on your behalf if this goes for judgement. In my state we have a vexatious denial of payment law (which comes with punitive fines), so my third or fourth letter always contains that word. Something like, “This is my fourth letter on the matter, and it is impossible for me ascertain whether my continuous denials are the repeated result of errors or if they stem from vexatiousness.” Or I point out how “vexing” this is. It lets them know that if I sue them, that it’s got the potential to be unusually expensive.

    One last tip. Don’t threaten to get an attorney until you really intend to. Once you do that, you’ve burned up the good will you might have had. You’ve lost that good will you were hoping to get your situation resolved. The billing people will very likely just sell your account to collections, and the insurance company may well just clam up and stop everything (unless they really think they are beaten, but that requires the polite prep that I outlined first).

  24. devbeth Says:
    February 1st, 2010 at 1:12 pm

    JLP – 1 – Document everything (I’m sure you have / are); 2 – contact the person who told you it was against the law – or better yet, the owner of that company and ask for the site reference in the law showing that the practice is illegal; 3 – remember the insurance commissioner is there for a reason; 4 – your insurance company is always interested in stopping fraud.

    I find it ironic that the very practice that would save US Taxpayers money (using an urgent care facility versus an ER – when appropriate) is causing so much consternation.

    Wish I was familiar with Texas insurance law – solving problems like this for my clients is what I do everyday.

    Good luck!

  25. Don Says:
    February 1st, 2010 at 2:45 pm

    Just to follow up. Tape your phone calls (if it is legal in Texas). I found that very helpful if only to review, because sometimes I would notice things when I played back the recording that I didn’t hear in the conversation.

    This is doubly true if you account goes to collections.

  26. Scott Says:
    February 1st, 2010 at 5:27 pm

    If you want to know about ER docs in Texas, call me. All ER docs in Beaumont belo0ng to Jefferson Medical in San Antonio and are not in ANY network. The ER itself is as a part of Christus or Memorial Herman. You get 2 different billings. Never ever pay from a billing, always wait for the EOB to pay your share.

  27. 7racer Says:
    February 1st, 2010 at 6:37 pm

    To Jaime #21). I have a bad feeling that the “Minor care center” is set up as an “office” entity. Regardless of what the billing department said, it is illegal to code for an “ER” visit when it was an office visit, just as it is illegal to code in correctly. That is why there are audits.

    To BG #22). [quote]But, you are missing the key part of our (consumer) negotiations: we just simply refuse to pay your bill.[quote] No I am not missing that key part. We know it VERY WELL. Sometimes it feels like trying to get water out of a rock. That is why we will charge a lower fee just to collect ANYTHING. That is much more reimbursement then if we send it to collections. How does it benefit us at all to charge you when we know you will simply not pay the bill. It does not benefit us at all to send you to collections! We would get more money if you just paid ANYTHING.

    Finally, in regards to your question about all of my patient’s in collections. ALL are at medicare rates. ALL. Unlike an ER, if the patient does not agree to a payment plan if they are indigent, we can turn them away where as the ER has to see them. Most of my patient’s that are in collections are those that have insurance but refuse to pay their copay or portion of a surgery bill. ALL are given medicare rates.

    To devbeth #24. I see the irony every day in my practice on the craziness of insurance. That is, I have a cheaper more effective treatment that one insurance covers but another will not. I have to use the more expensive treatment (cheaper for the patient because all they see is that they didn’t get a bill) because that is what their insurance pays for. All this did was add to this HUGE medical cost.

  28. 7racer Says:
    February 1st, 2010 at 10:51 pm

    Just a couple other aspects about the cost of medicine. As I mentioned above, most people that I send to collections are those that don’t pay their copay and deductible. In the old days many doctors would be generous and wave the patient’s copay. Did you know that is illegal under medicare? Just like falsely charging for services can lead to huge fines/penalties, waving copays can subject physicians to the same penalties. These became pronounced when medicare issued the “whistle blower rules” that paid the whistle blower a percentage of the fine. As crazy as this sounds, CMS ruled that waving of copay set’s an “incentive” for medicare patient’s to seek these doctors more favorably than physicians that do not.

  29. BG Says:
    February 2nd, 2010 at 12:05 pm

    #26 7racer) I hear you — if you are giving them the medicare negotiated rates, and they still don’t pay, then they are truly stealing from you (and everyone else) since of course you need to charge more to recoup those losses.

    Thank you for explaining the craziness. If you were to suggest any type of reform for healthcare, what do you think would be the one most beneficial change?

  30. 7racer Says:
    February 2nd, 2010 at 11:14 pm

    IDK, I don’t think it will be easy. I think the problem is that cost is out pacing inflation. If we are going to reel in those cost we have to make sacrifices and choices.

    I do think insurances companies need some kind of regulation. Sure they cover services but they also reap HUGE profits. Adding competition with a government model vs taxes makes more sense to me, though I wonder if it worked the other way around with private insurances available to those >65. I am NOT a fan of national health systems like the NHS in the UK. I did some training there, they did save a lot of money, by not treating.

    Also unlike physicians, there is no regulation on costs of medicines. Like you were asking me about what you thought the “worth” of suturing a finger, what is the “worth” of a drug. There is no competition nor oversight on what a drug company sets for the price of a drug.

    For physicians, it will be more a shift away from subspecialties and primary care for preventive medicine. Studies still show that would be beneficial in our society and lower cost. (I’m a subspecialist BTW).

    BUT, what I think we will have to realize that to lower the “COST” of medicine, the individual cost and services will change for the average american. That is, with lower profits for insurance companies, we will see lower payments to physicians and more “cost” induced medical decisions. That is, as Americans we have to become more accustomed to clinical diagnosis vs demanding expensive test.

    I know we are also the only modern society without universal medical coverage, but I am not a fan of the public option. If we are worried about cost, I don’t think we should add to it with a plan that will mostly be funded by the young and healthy.

  31. 7racer Says:
    February 2nd, 2010 at 11:30 pm

    Finally, while many of the foreign readers will tout the benefits of their universal coverage, I would like to bring up a few points.

    Though we do have the highest drug cost in the world, we are also have greatest amount of pharmaceutical companies producing new drugs for the rest of the world. We might see a drop in production of new drugs or a decrease in RD money for rarer disease and a focus on drugs that are more profitable.

    You will also see rationing of care. What most people with universal care in foreign countries don’t realize sometimes what they are missing. That is, if the prognosis is poor, or treatment deemed futile, no more expensive care will be given. Where as in the US, we tend to treat more with different newer therapies. Just look at the 34BILLION dollar alternative medicine economy from American’s frustrated with their perceived inadequate care!

    Finally, I do think office wait time will get worse. If you think about it, with lower reimbursements, the only way for us to try to make up for the lost revenue is to see more patients. Just imagine that, a cut of 20% in revenue, we have to make up for that by seeing 20% more patients a day?

  32. 7racer Says:
    February 2nd, 2010 at 11:37 pm

    Whoops, and I wanted to add, that I think letting insurance companies compete across state lines would also lower cost.

  33. BD Says:
    February 3rd, 2010 at 12:37 pm

    JLP, just be careful how far you take this principled stand. Collections are still collections, and while a PF blogger is in a better position than most to collect the evidence and file the disputes, if you refuse to pay, you will face the credit consequences.

    From the billing office’s point of view, they may very well feel that you are asking them to do something wrong in order to save a buck (or $700). Perhaps they really were informed that coding as an ER visit would be against the laws/rules, or they have all ER-coded claims denied by someone other than Aetna. They think you’re trying to get them to make an (illegal?) exception, and they don’t want the headache/can’t afford the liability that comes with bending the rules.

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