Doctor's Double-Billing Illustrates Broken System

Philip Betbeze, for HealthLeaders Media , April 12, 2013

Michael: We might be able to have conversations about this with the doctor's office.

Me: I understand healthcare is a mess, but in the past we never saw it. That was before people with insurance were paying for their own healthcare out of pocket. But y'all need to do a better job of negotiating stuff like this where the doc does no more work, but gets paid twice.

Michael: I'll put a note on your account about this sir.

Me: Thanks for your help.

So, that's where we left it, and that's where it will probably continue to be left. I like to think I am relatively sophisticated at navigating the healthcare system, but I'm at a loss on how to navigate this.

If this is what we can all expect to encounter when trying to resolve a simple primary care visit (or visits, depending on your point of view, apparently), it's tough to see how the individual consumer can ever be expected to alter practices like this. The only choice I have is to find a new doctor, and as the insurance company representative noted, all doctors do this.

What no one seems equipped to do is answer the question of why.

Philip Betbeze is senior leadership editor with HealthLeaders Media.
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23 comments on "Doctor's Double-Billing Illustrates Broken System"

Holly DeMuro (4/19/2013 at 11:36 PM)
Performing a sick and a well visit on the same service date is a completely legitimate billing practice

ptrower (4/18/2013 at 5:40 PM)
I had a similar incident when I was traveling out of town and my son developed pink-eye. I went to an urgent care center run by a local hospital that was located in a separate building from the hospital and was clearly labeled as urgent care. After a lengthy wait, my son had his three minutes with the doctor, got his prescription, we paid our copay and left. A few days later, I received a bill from the hospital system for the balance due after the insurance paid. When I examined the bill, I found that I had been billed for the visit as an emergency suing the emergency service UB codes. The insurance refused to pay and I was being billed for the difference of about $450. I called the hospital business office and was told that they had all kinds of complaints about billing for the urgent care center but that the bill was accurate. I called the hospital's compliance department and had several lengthy discussions with them. I ran the coding by the Director of Chargemaster for the health system I work for and as I suspected there was no justification for how it was coded and billed. I was eventually able to convince my insurance to pay it as a doctor's visit but there was still $250 left that I finally paid in order to avoid going to collection.

Howard S. Siegel, MD (4/18/2013 at 2:17 PM)
The use of the -25 modifier (a separately identifiable condition) is nothing new to billing and coding and has resulted in changes to the description of the modifier in the past. Blatant abuse of this coding/billing practice has and will continue to occur so long as the system allows for it. What is more troubling for me is 1) Apparent inappropriate use of Antibiotic in an asymptomatic 2 year old, and, 2)the gall of the Pediatrician to actually bill for it. As a Pediatrician, I have seen multiple concerns during routine physical exams, none of which needed to be treated and none of which were billed for. That is the Art of Medicine and not the Business of Medicine. There will always be those physicians that maximize profit over relationships.




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