One of the things that I do a lot here at our practice is talk to parents about their health insurance coverage. The conversation is usually about why they have a balance on their child’s account.
Health insurance is very complicated. At our practice, we deal with health insurance all the time and even for us, it gets to be very complicated sometimes.
Today, I had a conversation with a patient’s parent regarding medical billing issues. After explaining some in-and-outs about why we do certain things, the parent mentioned she had no idea things were the way they were and now understands why doctors’ offices have to do what they have to do.
She also mentioned that we should do something to spread the word. She said, “I think it is important for other parents to know this. Otherwise, how are things going to get better?”
I thought her idea to spread the word was very good. Therefore, I decided to summarize our conversation in an effort to help other parents understand, at the very least, a portion of medical health insurance.
Coding — a lot of what doctors do
At a restaurant, generally you’ll get an itemized check that shows all the things you’ve ordered. Doctors do the same thing, but they do it in the medical chart.
Virtually every doctor who accepts health insurance uses codes (called CPT codes) that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these things are “coded” separately.
Why do docs do it this way?
These codes are used by the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. In other words, the health insurance company (the one actually paying for the services) wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does as a code.
For example, if you are coming in for a child’s well visit, the pediatrician will submit a “claim” to the insurance company using the following codes:
- Established Well Visit – 99392
- Developmental Testing – 96110
- Hemoglobin – 85018
- Finger/heel/ear stick – 36416
- Lead Testing -83655
- Hearing Screen – 92587
If the child gets immunizations, those have codes too.
- DTAP-IPV – 90696
- Flu – 90660
Vaccine administration also uses a distinct set of codes. To further complicate things, some vaccines have a single administration code used with them, and others have multiple administration codes for a single vaccine.
- Admin – 90460
- Admin – 90461
Oh, by the way…
Let’s say while you are in the examining room, you ask the doctor, “Ya know doc, little Lisa here has been pulling on her ear lately… she may have an ear infection. Can you check that for me really quick?”
This question requires the doc to perform an entirely different assessment than the well visit the child was getting.
The doctor, in order to show the insurance company that she did a completely different assessment, codes the ear pain diagnosis and adds a 99213 – which is an evaluation and management code that documents in the chart and on the claim to the insurance company that the doctor also checked the patient’s ear.
But we feel like we are being squeezed for every penny
Parents often think when they are looking at the bill that the doctor is nickeland- diming parents, when in reality; it is the insurance company that requires the doc to show their work in this matter.
The health insurance company doesn’t accept the doctor telling them, “I did a well visit — pay me our agreed-upon fee.” They want to know all the things the doctor did during a patient’s visit so they can decide how much they ought to pay the doctor for his/her services.
Since most patients (or in the pediatrician’s case, parents) don’t pay the doctors directly, but rather the health insurance company, they want to know what took place during the visit so they know how much they ought to pay the doctor.
It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra.
Health care services are a la carte as well.
Why then do patients have balances if insurance ought to have paid?
The insurance policy that a patient has chosen may not pay for all the services the doctor performed. So when the doc’s billing staff submits a claim for a visit, the health insurance company often comes back and says, “We are not responsible for these codes/services; these are the member’s responsibility per the member’s health insurance policy. ”
For example, the health insurance company may say, the policy your patient chose pays for a vision screen, but not for a hearing screen. Or they may say, we cover the well visit code, but not the ear ache code at the same time as the wellness visit.
Doctors get stuck with the bill
The doctor, already having performed services, now has to go to the patient and say, “Hey, remember that school physical I performed and you asked me about little Lisa’s earache? Well, your insurance says that the policy you have doesn’t cover the earache part, so I’d like to be paid for the work I perform in assessing your child’s earache.”
Of course, doctors don’t actually say that, but when a parent gets a bill for the earache, that is in essence what the doc is trying to say to the parent. And if one looks carefully at the explanation of benefits (that document that the insurance company sends after they process a patient’s claim) one will notice they give an explanation as to why they are not going to pay the doctor for the service.
Funny how things work
Here is an interesting, but crazy fact. In many cases, had the doctor deferred the earache question and told the mom to make another appointment to address that issue during another appointment, the health insurance company would have most likely paid for the office visit.
However, had the doctor done that, the patient would have most likely gotten upset at the doctor. By treating the earache question during the wellness visit, the doctor runs the risk of not being paid despite doing the work. On the other hand, not addressing the ear ache, the doc runs the risk of upsetting the parent, who will probably think the doc is trying to squeeze another $30 copayment, which is clearly not the case.
Cutting cost — not always a good idea
One of the major problems with this is that patients don’t understand what they are financially responsible for. Or, it’s often the case where patients don’t understand what type of health insurance they’ve purchased.
Just like with anything else, you get what you pay for. But patients overlook this issue when purchasing health insurance. They usually look at the monthly premiums and choose the lowest one. But by doing that, they are often reducing the amount of coverage, which means patients will get stuck with larger portions of their medical bills.
Growing trend to save cost
The health insurance company, in an effort to keep their premiums low, have shifted the cost to customers and their doctors. While in the past health insurance companies may have covered 100%, now they are reducing the monthly premiums but only covering 70% of one’s medical expense. Hence all the high deductible plans out there.
Why wasn’t I told they insurance doesn’t cover?
In our practice – which is a small three-provider practice – we see on average 60 to 75 patients daily. Add to that there are virtually thousands and thousands of different health plans. In fact, we have patients whose parents work for the same company, but because they are at different pay grades, have different insurance plans.
The answer is, we don’t have enough manpower or time to sit on the phone verifying every single patient’s healthcare coverage. I know of practices that do, and God bless them. But as a practice we believe it is the patient’s responsibility to find out what is covered and what is not covered. The more time we spend on the phone with a patient’s insurance company, the less time we are able to spend providing health care for our patients.
As a practice, we consider that treating patients based on what the insurance covers and what it doesn’t, instead of treating by what the patient actually needs, is an unethical way to practice medicine.
Although most doctors that I know will take into consideration health insurance stipulations, they will not compromise a child’s health as a result of health insurance restriction and cheap health insurance coverage plans.
I hope this post will give all that read it some insight and perspective on medical billing. If you have a question, or don’t understand why doctors’ office do medical billing, feel free to leave a comment and we will try to address it.
Oh, and thanks for reading…
Brandon Betancourt is a practice administrator for Salud Pediatrics.
You can follow him on Twitter @pediatricinc.