Doctor/Insurance question

[MerryBlooms]

I'm really not sure where this should be posted, so I'll depend on the good judgment of our Mods/Admin to determine the placement.

Has anyone else lately been charged $25 by their primary physician to receive/share information from patient's other doctors? I am under the care of 2 other docs besides my primary, the primary is now charging $25 each time my other doctors send her an email update of my exam/condition.

Also, my primary is now charging $120 per office visit - insurance says 20% of $80 is reasonable.

Pneumonia shot - $80 for the shot, $25 for the administration of the shot, $120 for the office visit. What the heck does the $120 cover?

Cripes.

Add to that the 33% increase in my premium over the last 18 months. Yes I have a PEC, due to a prolonged hospital stay, but my current insurance has only been billed for regular check-ups. I'm afraid to ask questions in fear of being dropped by my insurance or primary.

[pitohui]

1. i'd file a complaint with your state's medical licensing board EOM

,

[gateley]

2. Kicking to keep this visible -- sorry, I don't have any answers for you. nt

[MerryBlooms]

6. Thanks for the kick.

n/t

[uppityperson]

3. There is a set fee that they can charge for copying records, at least here in WA

That sounds about right for what they CAN charge, but I know of few who actually do that. It sounds rather unethical.

Are you saying $120 for office visit, and you pay 20%? If you could clarify, would be good.

Did you see anyone when you got the pneumonia shot, or was it just given by a nurse/med assistant? If so, they should not charge for "office visit".

All the way around, this sounds unethical to me.

I am a health care provider, not primary care, who does insurance billing for my business, and am a nurse working as a nurse also.

Edited to add, I checked to see if there is an Oregon Insurance Commissioner, they may be able to help since charging outrageous things "because insurance will pay" can fall under them. Approach part of it through an insurance fraud thing perhaps. Here's links.

http://insurance.oregon.gov/
http://insurance.oregon.gov/consumer/consumer.html

[MerryBlooms]

8. I'm paying 20% of the determined reasonable (after 500 ded)

and then getting billed from the doc office for anything above what the insurance says is reasonable.

My doctor administered the pneumonia shot.

I'm afraid to make waves for fear of being dropped. I happen to be a pre-existing patient and am thankful for being insured and I know I could be dropped at any time.

[county worker]

4. I used to be a controller of a medical clinic so maybe I can shed some light.

Doctors negotiate a reimbursement rate with insurance companies. In our case the clinic did because the doctors were employees. Medicare pays a scheduled rate. Most insurance companies pay the Medicare rate plus some percentage over that. Some times it was Medicare plus 10%.


The doctor or clinic does not have to contract with insurance companies if they don't pay what the doctor or clinic thinks they should. In that case if you have that insurance you pay the difference between what the doctor gets with out a contract and what the doctor thinks he should get.

Every thing a doctor does has a CPT code. That code number is 5 digits. 90801 is the CPT code for a mental health evaluation that takes 15 minutes. Every CPT code has a rate which is the rate that medicare pays. Insurance companies pay that rate for the CPT code and some percentage more or less. All insurance companies set their own rates for each CPT code.

An office visit has it's own CPT code as does the administration of the shot. The medication does not have a CPT code but is billed at a rate also.

The doctor writes up his notes and a certified coder adds the CPT codes based on the doctor's description and the billing department bills your insurance company or medicare or medical in CA or you.

My guess is your doctor thinks he does not get reimbursed enough for treating you and has raised rates to make up what ever difference there is.

There are fees that clinics charge for sending medical records also. It is not a standard thing I think.

Ask for the CPT codes for what you are paying and check them out on the Medicare web site.

Someone please correct me if I am wrong here.

[uppityperson]

7. And about those "15 minutes". It does not always equal 15 minutes, rather like car repair.

When you get something done on your car, it is standard practice to look up "expected" amount of time for a procedure, and bill the hourly rate times the amount of time in the book. It may not take (for example) 1.25 hours to change your radio station, but that is what you get billed for.

Same with health care/insurance stuff. 15 minutes is considered 1 unit, and billing is by a unit. This is why there can be short, medium,long office visits on a bill. It doesn't mean 15 minutes, 30 minutes, 45 minutes, but that is how it insurance companies see it to pay it.

So, insurance/you may be billed for a "medium office visit"/2 unit/30 minute visit, but were there only 17.34 minutes and talked about 2 minor things.

Supposedly the time/units/actual visit should be somewhat related, but like getting your car repaired, it isn't always so.

[county worker]

9. Yes, I agree with all you said.

in my example 90801 is a 15 minute visit and the rate is 129.21 per unit (15 minute unit)
90805 is for the same visit but for 20 to 30 minutes at a rate of 64.15 per unit or two units at 64.15 = 128.30. After 16 minutes it is rounded up to 30 minutes or two units for 128.30. These are facility rates.

On edit:
In my example the doctor gets paid a bit more for the 15 minute visit. Not much but do a lot of patients and it adds up. So a doctor that is more mercenary will only see you for 15 minutes or less because he doesn't make any more money by spending more time with you.

[sinkingfeeling]

5. I think I'd find another primary doctor. I'm a cancer patient and I even have a dentist and an oral

surgeon exchanging information with my doctor, oncologist, radiation oncologist, ENT. That's part of the 'team' concept in treating cancer nowadays. It would cost a fortune for each to charge $25 to put something in their files on me.

[ecstatic]

10. My ex-gyn did that. I needed the records ASAP and the rude secretary

told me I'd have to pay something like 30 bucks and wait 2 weeks. They'll never hear from me again. I'm so disgusted that I'm in between PCPs and Gyns right now, despite paying hundreds a month for insurance.

[aint_no_life_nowhere]

11. Anyone see Frontline last Tuesday about healthcare in other countries?

They sent a reporter to several countries (Germany, Japan, the U.K., Switzerland). Some countries set caps on a doctor's billing, per procedure. Some doctors were complaining that they were only making $80,000 to $120,000 a year compared to $200,000 or more for doctors in the U.S. with a similar practice. Conservatives want to cap lawyer fees in medical malpractice cases. Would capping doctor fees per procedure (not by time involved) be a good idea? Even if you factor in the high cost of a medical education in the U.S. compared to other countries, U.S. doctors are probably coming out well ahead over the course of a lifetime if it is true that they are making double or more what doctors elsewhere are making.