Doctoraaron, away from the office.......
It’s been a long time since I did any blogging. Work as a family doctor has been tough. Days are long, usually ten hours and then an hour or two at home. Last year I did okay financially, making $130,000, but this year has been harder. Each of the last two months I lost $25,000 and the prospect for any net income this year looks bleak. But I am not really here to complain about me. I have a lot of money saved to weather such challenges and I was blessed with rich parents so I have a good cushion if my own situation doesn’t improve.
But the Trump “economic boom” has really not trickled down to my patients and they are suffering. I thought I would experiment with a bit of storytelling without much pontification about what we need to do to change things. I hope that comments will enlighten. Instead, if readers find the topic of interest I will offer a few, essentially unedited, case studies to stimulate thought.
First, the story of RS, an ordinary tale, repeated at least once a week. RS, a 29 year old graduate student, came in for his initial visit in September, a get acquainted visit where we discussed his concerns about blood pressure, headaches, and back pain and where we attended to a few health maintenance concerns. It was scheduled as a 30 minute visit but went on a bit longer. His insurance was billed for the visit but declined to pay as a deductible was applied. He was surprised and so wrote me this note---
Hi, Doc-
I’d like more information about the designation of the billing for my recent office visit. I would have expected the visit to have been classified as an “annual physical” sort of activity, which I understand is covered as preventive care and covered by my insurance even before my deductible is reached. (Note from doctoraaron: this is an Obamacare mandate, designed to improve access to preventive services) The office visit part of the bill was not covered at all by insurance, only negotiated down in rate, so I’d like to understand why this was different from what I expected and whether it was/was not defined as preventive (and if not, why not).
I have a bill for this due on 25 October. What is the consequence of missing that (eg., because we are still discussing)?
To get a note like this is upsetting. I feel bad when medical care that I provide results in financial hardship, but I have to make a living too, and I always try to provide care honestly and with real concern and attention to my patients. But what really upset me is that we needed to discuss this issue at all. Why should getting health care result in such a dialogue? In any event, I felt that I needed to respond and so I decided to do so in a fairly comprehensive way-—
Hi, R--
Fundamentally, you got this bill because our health care system is fucked up beyond belief. In a just and economically efficient system you would have gotten no bill at all as appropriate medical care would be paid for through an improved Medicare for All in which payment would come from a progressive tax-financed system free of deductibles and copays.
Until people get motivated to advocate for this change we are stuck with what we have.
What we have is a system in which doctors are required to code each visit with diagnosis codes which accurately documents what took place in a visit. This coding process is very subjective and can reasonably be done differently in any given encounter. When we are aware at the time of a visit that how we code may make a difference on a patient’s pocketbook if we code in a preventive manner or in a problem-focused manner then we try to code in a way that saves our patient’s money. On the other hand, if this issue is not in the forefront of our minds at the time of an office visit then we simply code for whatever seems most factually correct. To compound this problem, with many insurances this distinction doesn't make any difference..... but in your case it did.
During your visit we addressed both preventive issues— lifestyle, vaccines, routine testing— and some problems-— blood pressure, back pain, and headaches. We could have billed it any number of ways, as a preventive visit, as a problem-oriented visit, or as both. As it turns out, we probably would have earned more had we billed differently…..
Nothing will happen if you do not pay your bill on time other than that we will not have been paid in a timely fashion for our services and you will likely receive another bill asking for payment. I understand that you are a graduate student and that paying a doctor bill may be a hardship and not your first priority. If you would like, we can arrange a payment plan and I can also see if we can retroactively change the coding to classify this as a preventive visit.
In any event, however, I hope that this addresses your questions and I hope even more that your greater understanding of how the system works will lead you to work for change.
