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View Diary: Greedy big-profit health insurers charge patients for talking too much -- yes, really... (115 comments)

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  •  Wow--there's a lot of emotion in this thread (3+ / 0-)
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    isabel, therealdrlaura, Rachel Q

    I'm a Pediatrician in Texas.  I deal with many of these issues on a daily basis.  As I see it, there is a big disconnect between the way the patients view the issues and the way the providers view them.

    First, the statement in the diary title is not accurate.  The patient is not being charged extra for "talking too much."  As several other physicians who have commented in the thread pointed out, when a significant additional problem is dealt with in the course of a preventative care visit, it is properly coded and charged separately.  The separate office visit code we use has a -25 modifier, which lets the insurance company know that there were additional significant services provided during the preventative care visit.  The reimbursement for a -25 modifier visit is not as much as if the visit was a stand-alone sick visit.  

    The separate visit charge should not be used if the extra service provided did not require the provider to to do substantially more work than he or she would have done in the regular preventative care visit.

    For example, if I am examining a toddler for a preventative care visit and I determine that the child has an ear infection or a cold, I do not charge an extra visit (-25 modifier) charge, because all I had to do extra was write a prescription or give advice about proper treatment of a cold.  However, if the patient is in the midst of an asthma exacerbation during the well-check, and I have to give nebulizer treatments, frequently re-evaluate the patient, review the asthma management plan, prescribe new medications, give detailed instructions for asthma care, and arrange for follow-up, then it would be wrong of me not to charge for the significant extra service.  (I use the term "wrong" because I am the employee of a clinic--I would be undercharging for my services and affecting the clinic's bottom line.)

    Every doctor is different, and I will admit that I have run across doctors that refuse to see a patient for more than one problem at a time.  I personally think that is ridiculous, but everyone runs their own practice their own way.  Most doctors I know, however, routinely go above and beyond what would be expected of them in order to give the best care possible to their patients.

    For example, here are a few of the things I do for my patients on a daily basis (without charging extra).  I try to keep up with the medications that are preferred on our state medicaid formulary and the major insurance formularies so that I can prescribe the least expensive medications possible for my patients.  I research costs of commonly prescribed drugs at local pharmacies so I can tell my self-pay patients where the cheapest prices are.  I try to maintain stocks of sample medications and reserve them for my patients who have no insurance or high co-pays or deductibles.  For that matter, I question the patient's family about whether they have high co-pays or deductibles before I prescribe what I know to be an expensive brand name drug.

    I don't order unnecessary lab tests or x-rays.  If I have a patient come in with chronic knee pain (but no change in activity level), I don't order an x-ray before I refer them to the orthopedic surgeon.  I know for a fact that the ortho doc is going to get an x-ray and I also know that the chances of an x-ray showing anything significant in that case are slim to none.  If I do need to order lab or x-ray, I try to arrange so that it can be done on the same day as an office visit so that the patient only has to pay one co-pay.  If I walk into a patient's room and they obviously have a problem that needs to go directly to a specialist (for example a huge boil that needs to be lanced or a foreign body in the eye), I waive my co-pay so that the patient doesn't have to pay two in one day.

    Despite my efforts to do the best job I can for my patients at the least cost to them, I frequently have patients that try to take advantage of the system.  We have convenient care hours in the early morning for simple sick visit problems.  Frequently a parent will bring in a child with chronic abdominal pain, or recurrent migraine headaches, or some other problem that requires a time-consuming work up.  These are not "convenient care" problems, but we handle them anyway.  When I gently tell the parent that "this isn't really a convenient care problem so next time you should try to make a regular appointment," they usually just give me a blank look.  We also have Saturday morning walk-in clinic and we will have parents try to walk in for a well check and immunizations for a child.  We have to explain that we don't have the child's chart available to record the immunizations and we don't have the personnel necessary for the much more involved and time-consuming well checks on Saturday.

    Almost anytime I walk into a room that contains two children when only one has an appointment, I know I will probably be hearing "Doc, could you just look in little Johnny's ears too as long as we are here?"  I know they are trying to save a second co-pay for second child, but my practice has bills to pay too.

    So the result is that the patients feel that the doctors are just trying to get as much money out of them as they can, and the doctors feel like the patients are trying to get something for nothing.  Neither of these is the truth.

    The best answer is to try to find a doctor whom you trust and who treats you and your family members with dignity and respect.  Don't be afraid to tell your doctor that you have a high deductible and will be basically paying everything out of pocket.  Most doctors will do everything they can to help you minimize your cost.  Don't be afraid to ask your doctor or nurse why certain tests or x-rays are being ordered and whether it would be possible to minimize expenses in that regard.  If you are concerned about a particular problem or symptom and your doctor seems to make light of it, explain to the doctor what you are worried about.  We might have missed the importance of a symptom, or we might be able to reassure you that the thing you are worried about is benign.  

    Be kind to your doctor and the office staff by being honest about the reason you are being seen so that sufficient time can be set aside for your visit.  Don't demand to be seen immediately for a chronic problem that is not currently flared up.  Don't ask your doctor to diagnose multiple family members with just one co-pay, or to prescribe medications to family members who aren't even present.  Don't walk in with a list of the tests you want to be performed that day or a list of new medications you want prescribed.  Trust that your doctor has had many years of education, training and experience and probably knows better than you do which tests, procedures and medicines are indicated for your condition.

    Finally, when you are waiting for an hour or two past your appointment time, don't blame the doctor.  Blame those other patients who don't follow my advice and who fill up the doctor's time with unanticipated time-consuming work ups.  Or you can blame the sick baby over in the hospital nursery that I've been trying to keep alive until the life-flight helicopter can get there to pick it up.  (It doesn't happen often, but it does happen out here in the small towns where we don't have neonatal specialists.)

    The health care system in America will continue to get more cumbersome and confusing over the next few years as the ACA is implemented and all parties involved work to comply with its provisions.  In the long run I do believe it will be an improvement over the old system, but in the meantime there will be growing pains.  And we can all still dream of a future with a single payer system!

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