Doctor's Double-Billing Illustrates Broken System

A pediatrician's billing policies—and an insurance company's inability to negotiate better terms—perfectly highlight the difficult work in store for those of us who would like to see more value in healthcare.

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.
terri l. (4/17/2013 at 5:38 PM)

If you quoted the representative at your healthplan correctly he should be reprimanded for being so derogatory towards the provider. Both of you could use a class in correct coding guidelines before you attempted to discuss this topic with the public. A preventative visit does not include dealing with a chronic or new issue regardless if it was found during the exam or presented by the patient. In fact many health plans have policies in place specifically addressing this issue. Health plans and employers need to educate patients about what is and is not included in their "free" preventative visit.
john, md, jd, mba (4/17/2013 at 4:14 PM)

I can confidently say that this is unethical, even if not illegal or not explicitly prohibited. The same skill required to determine a "normal" ear was used for an abnormal determination in what appears to be an asymptomatic patient. Therefore, the procedures performed are identical- unless of course your pediatrician doesn't include ear exams for well children. The subsequent diagnoses may change during the visit but the only service you received was a well-child visit. I won't even approach the quality issue of medicating an asymptomatic otitis. That alone should have been a QA flag for the insurance company. You've also noted something extremely important. As long as physicians are paid per diagnosis rather per service- this abuse will continue. You have no way to determine if the otitis diagnosis was even real.
Gus Geraci (4/16/2013 at 4:08 PM)

Understanding medical billing is a challenge. Others have already addressed the fact that the physician was correct, and it was not double billing, because you got two services. I won't delve deeply into the wisdom of antibiotics for an apparently asymptomatic ear infection. That's a clinical discussion that you can research. However, this was "small potatoes." Imagine being a Medicare patient, in for your "completely covered" screening colonoscopy. A good thing, right? A polyp is found and removed. That visit is NO LONGER covered in full, but now subject to deductibles, because it is no longer screening. Imagine you are a patient put into a hospital bed for 48 hours for treatment and evaluation of an acute illness. On discharge, you find out you were NEVER "admitted" to the hospital, but were on observation the whole time, which is considered outpatient, and all charges are now subject to different (and much higher) co-pays. Welcome to medical billing 2013.
Todd C (4/15/2013 at 10:47 AM)

An analogy might be your car. If you have insurance coverage for your vehicle due to an accident and you bring it in, that's covered. However, if you also asled for an oil change and service while you had it in the shop why would you be shocked you got an additional bill? The physician should have communicated it in the room though, patients do struggle with this concept for school physicals, workment's comp, well checks, etc.
donstumpp (4/15/2013 at 10:46 AM)

First, this is not double billing. You may have had one visit, but there were two services given. The annual checkup, then also Evaluation and Management for the ear infection. Proper CPT coding with add the modifier -25 to the office visit. Some payers reduce the office visit allowable, since this separate service does have overlap with the well visit (check in, history, etc) I find it interesting that many time people do not understand things until they are hit with it. This "issue' has always been around, and as you state, is now a bit more highlighted because of the annual wellness being covered and patients having to pay more of the bill. Our physicians frequently have to tell patients the annual visit is not to go over all your ailments and discuss (ie treat). That then becomes an E&M visit. Of course, not too many years ago, well child was NOT covered by insurance and the doctor did the patient a favor by finding some acute problem. Then the patient only had the $20 copay instead of paying an $80 non-covered visit, but that's another topic!
Bill B, MD (4/15/2013 at 10:00 AM)

This doctor is criticized not for gaming the system but rather for playing by the rules. The discovery of otitis required diagnostic skill, medical decision making, extra work, and assumption of liability. Reform of the payment system is sorely needed, but a pediatrician should not be faulted for doing his best to provide good care and charging fees to which the patient and insurance company have agreed.
Kay Kirkpatrick, MD (4/15/2013 at 9:56 AM)

If the child had an ear infection the child was not "well". The decision-making for treatment is not just writing a prescription. This is a common occurrence and I'm sure the mom wanted her child's infection treated. Not having to schedule a separate appointment was a convenience. Maybe the family should have gone to a "minute clinic" for treatment. You can bet that would not have been free. This is typical of patients who really don't understand how their health insurance works and the doctor ends up being the bad guy for just doing his job and following the insurance company's rules.
John Morley (4/14/2013 at 10:03 PM)

I'm surprised the comments are as focused as they are on the (Complexities) of billing when the issue of antibiotic administration for a asymptomatic 2. y.o. is crying out for comment. The Clinical Practice Guidelines of the AAP for Acute Otitis Media further indicates a discussion with the parent(s)/caregivers is warranted but no mention was made of any discussion and the potential to watch and observe. And no mention of a/an (?) incentive to change the visit from a well child to a sick visit. What impact does the treatment of this asymptomatic child have on "The bottom line"?
steven wertheim, m.d. (4/13/2013 at 5:46 PM)

your article does illustrate clearly one of the big problems with healthcare-the consumers attitudes towards paying for anything or acknowledging quality and effort. if you took your car in for an oil change and they found a problem with your tires, you would have no second thoughts of paying for that. if you had a coupon for a free gift at the store, and decided when you were there you wanted to buy something else, you would pay for it. the visit was "simple" yet if the doc missed something important he would get sued. the idea that there is no extra effort in diagnosing, documenting and treating an ear infection above an office visit is really an insult to your doctor. until the patients don't come to expect "everything" for free, and understand the costs and complexities and where they are in the system, we will not have a fix. but please don't blame the doctor-when you need him in the middle of the night you won't be thinking about how much he is going to get paid
Mary K Parker (4/13/2013 at 2:45 PM)

If the pediatrician had identified the ear infection, but you had not filled the prescription, would you still have been billed for a routine wellness visit? It seems to me this is an "incidentalitis" (since it's an infection, not an abnormality on a film).
Katalin (4/12/2013 at 7:48 PM)

I agree with Cindy Shields. Don't give up. A well visit for a 4 year old includes "Care of a small problem or preexisting condition that requires no extra work". My quote is from the billing regulation.
M Heasley (4/12/2013 at 6:27 PM)

Why? Because you think the first visit - where your child is well - is free. It is not free for the Doc who pays for lights, utilities, and nursing staff, along with training and equipment. The Doc is not allowed by the insurer to charge for the well-visit. However, if your child has an ear infection then the Doc must do a lot of additional thinking, whch is really his/her stock in trade. He cannot just write a prescription, he must use expertise to decide if a prescription will be benefiical, considering any downsides and newest medical information, consider other conditions your child may have or other prescriptions they may have taken and have reacted to. The Doc wants to do what is most efficacious and safe for his patient - and you want him to do this, too. This is what you pay for when there is a higher co-pa "ill-child" visit which grows out of a "free" "well-child" visit.
Meriann Anderson (4/12/2013 at 5:09 PM)

I would agree with a number of the comments here particularly with correct E/M level assignment. A separate problem-based E/M level can be assigned only if the condition being addressed requires significant and separate work up. I'm not sure of the percentage of claims "reviewed" by the insurance companies but as a compliance manager myself, our company staffs credentialed coder/auditors to provide this service to clients. Regular reviews of documentation validation is essential for compliance. I believe most payers have this process in place and you could request this specific encounter be reviewed. Just a suggestion.
Ruth Ann (4/12/2013 at 4:38 PM)

I work for insurance companies, but here I have to agree with others who've said the doctor doesn't seem to be at fault. If you go in for just the well visit, and a problem is found (especially a pretty small one, like this), the insurance should cover that the same way they would a well visit where nothing is found. The fact that the visit is coded differently doesn't require them to cover it differently. Otherwise what is the point of 100% coverage for preventive services? If you never found any problems on these visits, they would be a complete waste anyway!
J Marek (4/12/2013 at 2:43 PM)

You're right. This is a problem. The problem is insurance coverage for routine care. It leads to huge admin costs and the public not valuing healthcare and price shopping. You probably wouldn't blink an eye or spend so much time or energy on the bill for the routine oil change and maintenance on your car. You'd either value the relationship and experience at the dealership or go to a quickie oil change place. More govt oversight and "coverage" will lead to more of this.
Thomas A. Raskauskas, MD (4/12/2013 at 12:49 PM)

I would like to discuss this article with you, as there is a misunderstanding of the billing rules. The doctor did not bill twice, but is billing according to the billing regulations of covered care at a preventive visit, as opposed to a problem based visit. It is only recent that the insured are noticing this, as there are higher deductibles. The flip side of this is that now that individuals are paying more out of pocket, they are looking closer at the billing practices. With that said, we need health reform, which I have been working on for the last decade. I would like to discuss this.
trout (4/12/2013 at 12:32 PM)

Thank you for exposing this example of overpayment. But may I add that to be comprehensive you must also work to expose the equally numerous examples of underpayment. To stay in business, providers must maximize their legal opportunities to get paid to balance the goods and services that are provided with no reimbursement at all. I am not a physician but I do work for a healthcare provider and I witness every day our struggle to remain viable and exist on the razor thin margins on the bottom line. trout
Susan Taylor Proctor (4/12/2013 at 12:20 PM)

Oh Philip, where to start? Or, is this article some kind of joke? You would benefit from a better understanding of correct CPT and ICD-9-CM coding rules. All the payment models are predicated on these rules. Remember HIPAA, the transaction and code sets? Really, you don't know this stuff? Nothing you described in your article indicates you were taken advantage of or incurred improper charges. Everything in your article describes how sadly uninformed many folks are, especially in the industry, regarding the basic coding rules that our healthcare payment system is based upon. And, PLEASE, none of our healthcare benefits are FREE! Someone pays. You might have a coverage benefit under your plan that allow no out of pocket cost to you at the point of service, that that is not free.
Cindy Shields (4/12/2013 at 12:17 PM)

Your doctor should not have charged for anything in addition to the preventive visit (CPT code 99392 age 1 through 4 years). The CPT book specifically states that an insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation & management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported. Your insurance company should have denied the extra code as bundled into the preventive visit, and the EOB should have had $0.00 under patient responsibility. You should fight this by taking it to a higher level with your insurance company as well as writing your physician and not paying for it. It's at least abusive billing on the part of your physician, and possibly fraudulent. Don't give up.
Julie Fulcher (4/12/2013 at 11:56 AM)

I agree that the current convoluted healthcare billing system leads to unnecessary cost and frustration. It seems like the core of the problem is the doctor's incentive to bill more visits. If the health plan were to negotiate a capitated method for paying primary care doctors - i.e. a flat rate with bonuses for providing quality care and keeping patients healthy - some of this could be avoided. I understand that it is a very complicated and tricky business to set capitated rates correctly, but it seems like that is the way we need to move and learn as we go.


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