# Another pitting of the US health ”care” system **URL:** \ **Category:** The BBQ Pit\ **Created:** [July 26, 2022, 11:00am UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581 "2022-07-26T11:00:55Z")\ **Posts on this page:** 20\ **Page:** 12
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [July 14, 2024, 11:57pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/221 "2024-07-14T23:57:42Z")
There’s me explaining how I understand the system and then there’s my opinion on whether it is good. I don’t think it’s a good system. I do think most people have a choice in the basic terms of their plan. I don’t think it’s wrong, under the existing system, to categorize a routine visit as E&M if there is actual management of a disease. I do think a $100/$500 ins/pt split is outrageous. I don’t think it _should_ come as a surprise to the patient even under the flawed system we have. I also think surprise billing sucks and should be pitted. It has been made illegal for obvious reasons, but in practice it is still a problem. Things like this > [@Can anyone help me with a work problem?](https://boards.straightdope.com/t/can-anyone-help-me-with-a-work-problem/1003723/17): > > It would not be good for me to be fired, but it’s also not good for me to find another job now for many complicated reasons. A lot of this is healthcare-related, and my life will be a lot harder if I can’t wait until September to find another job. demonstrate what an unmanageable wreck the U.S. healthcare system is. The idea that you should have to put up with a hostile work environment for months on end because otherwise you might lose access to your doctors, treatment &etc is plain wrong. ~Max ---
**Author:** ![Mighty\_Mouse](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/mighty_mouse/32/7776_2.png) [@Mighty\_Mouse](https://boards.straightdope.com/u/Mighty_Mouse)\ **Post date:** [July 14, 2024, 11:59pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/222 "2024-07-14T23:59:44Z")
> [@Max\_S](#): > > There’s me explaining how I understand the system and then there’s my opinion on whether it is good. I don’t think it’s a good system. You are explaining your participation in a scam. ---
**Author:** ![kayaker](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/kayaker/32/441_2.png) [@kayaker](https://boards.straightdope.com/u/kayaker)\ **Post date:** [July 15, 2024, 12:04pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/223 "2024-07-15T12:04:35Z")
My sister has three sons. When pregnant with #3, her water broke on the tennis courts. Her husband rushed her to the nearest hospital, which was where she worked as a nurse. She gave birth on a gurney in a hallway as they were trying to get her admitted. It was the epitome of an easy delivery. Her doctor stopped by to chat. Her anesthesia dude asked if she required pain meds. It was later in the day so she went home the following morning. Her insurance covered everything, but she was shocked to see that the doctors had all billed as if they’d done something. The anesthesiologist who asked if she needed anything billed as if he’d been there for labor and delivery. ---
**Author:** ![Alessan](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/alessan/32/465_2.png) [@Alessan](https://boards.straightdope.com/u/Alessan)\ **Post date:** [July 15, 2024, 12:27pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/224 "2024-07-15T12:27:34Z")
And in the meanwhile, the nurses did all the actual work. ---
**Author:** ![kayaker](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/kayaker/32/441_2.png) [@kayaker](https://boards.straightdope.com/u/kayaker)\ **Post date:** [July 15, 2024, 12:28pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/225 "2024-07-15T12:28:53Z")
Nurse. My nephew was delivered by a nurse, who my sister worked with. (He’s the weird nephew) ---
**Author:** ![Mighty\_Mouse](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/mighty_mouse/32/7776_2.png) [@Mighty\_Mouse](https://boards.straightdope.com/u/Mighty_Mouse)\ **Post date:** [July 15, 2024, 12:32pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/226 "2024-07-15T12:32:19Z")
This is what I’m talking about. Physician practices employ folks to review notes and “recharacterize” activity to maximize billing going right up to the line of easily provable criminal fraud. And that’s the SOP these days it seems. According to our friend Max, I can never get a routine physical because I have had some condition for 40 years, the treatment of which involves renewing the prescription I’ve been on for 20+ years. Because my doctor saying “x looks good” means disease management. Before these toads existed, everyone would recognize this as fraud. ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [July 15, 2024, 4:17pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/227 "2024-07-15T16:17:05Z")
You can get a routine physical. A physical exam does not include management of chronic disease. Once you add that in it’s still a routine visit, but it’s not preventative care. ~Max ---
**Author:** ![puzzlegal](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/puzzlegal/32/3827_2.png) [@puzzlegal](https://boards.straightdope.com/u/puzzlegal)\ **Post date:** [July 15, 2024, 4:42pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/228 "2024-07-15T16:42:18Z")
I’m sorry, but a routine physical does, in fact, include renewing the drug you’ve been on for 20 years to manage a chronic condition You’ve had for 30 years. And fwiw, my doctor does that every year and i get billed for the routine physical that is fully paid for. ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [July 15, 2024, 5:10pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/229 "2024-07-15T17:10:18Z")
I’m skeptical that it is billed as a “preventative” visit. MDs usually don’t throw money away. You can check your EOBs for the CPT code. It is “preventative” if the visit code is 9938X or 9939X. By definition preventative care does not include evaluation and management of existing disease. Most insurances cover diagnostic care visits (non-preventative evaluation & management, e.g. 9920X or 9921X), but for some reason **Mighty\_Mouse** ’s might not have. ETA: If your doctors have nice billing and aren’t greedy, they might even code it as 99393 or something and a separate line for 99211 (the cheapest E&M) with a modifier saying that service was secondary. But it doesn’t have to be that way. ~Max ---
**Author:** ![Pitchmeister](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/pitchmeister/32/3459_2.png) [@Pitchmeister](https://boards.straightdope.com/u/Pitchmeister)\ **Post date:** [July 15, 2024, 5:20pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/230 "2024-07-15T17:20:11Z")
I cannot begin to describe how bizarre, as a German, Max\_S‘s posts, especially the last one, read - is this something the average person is supposed to know about and keep track of, lest they need to declare bankruptcy after getting a splinter removed at their doctor’s? ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [July 15, 2024, 5:22pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/231 "2024-07-15T17:22:46Z")
In theory, you are supposed to know the difference between preventative and diagnostic care when you sign the contract for health insurance each year. The insurers also have websites explaining this and are legally required to inform customers that the law requires insurers to cover one free preventative visit per year. This is me explaining how the system is supposed to work. In practice, nobody knows these things because the U.S. healthcare system sucks. Most people know about the one free preventative visit per year, many conflate it with a routine physical exam. ~Max ---
**Author:** ![doreen](https://avatars.discourse-cdn.com/v4/letter/d/858c86/32.png) [@doreen](https://boards.straightdope.com/u/doreen)\ **Post date:** [July 15, 2024, 5:23pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/232 "2024-07-15T17:23:38Z")
Look, you can only say what your employer does - I just had my yearly no-copay physical (his office has resumed participating in my insurance) At which my doctor sent refill prescriptions to my pharmacy without coding anything on the claim about “management” or “diagnostic”, just like he doesn’t submit a claim if I call for a refill. I can’t access the claim with the codes yet - but this is what the summary says > Comprehensive, preventive medical assessment for an adult. This typically includes age- and gender-appropriate history, exam, counseling, education and necessary lab work. And I’m pretty sure he’s not throwing money away because they did bill $10 separately for a blood draw. ---
**Author:** ![Cervaise](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/cervaise/32/16693_2.png) [@Cervaise](https://boards.straightdope.com/u/Cervaise)\ **Post date:** [July 15, 2024, 5:25pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/233 "2024-07-15T17:25:01Z")
As an American who used to be neck deep in the hellscape that is the US health care system before moving to Europe and discovering civilization… yes and no. You _can_ try to figure this shit out but the medical-insurance mafia has an adversarial relationship with the public and makes it as difficult as possible to understand. Most people just give up and assume it’s natural for hospitals to fuck people over. ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [July 15, 2024, 5:28pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/234 "2024-07-15T17:28:53Z")
> [@doreen](#): > > Look, you can only say what your employer does - I just had my yearly no-copay physical (his office has resumed participating in my insurance) At which my doctor sent refill prescriptions to my pharmacy without coding anything on the claim about “management” or “diagnostic”, just like he doesn’t submit a claim if I call for a refill. Not only what my (former) employer did, but also what my doctors do. That’s nice of your doc to bill the visit as preventative, and to not bill for refills. I wouldn’t assume it’s standard practice everywhere. It may be standard in your region or it may even be specific to your insurance. With some docs and insurers those 2-3 minutes checking your symptoms and calling in the refill are billable, especially if it’s something that you have to be careful about refilling like steroids or antibiotics. ~Max ---
**Author:** ![doreen](https://avatars.discourse-cdn.com/v4/letter/d/858c86/32.png) [@doreen](https://boards.straightdope.com/u/doreen)\ **Post date:** [July 15, 2024, 5:33pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/235 "2024-07-15T17:33:10Z")
I absolutely don’t assume it’s standard - it’s been every doctor I’ve ever had that doesn’t bill for sending a refill - but sure , that could be restricted to the three insurance companies I’ve had in the last 35 years. Or to my area . But you’re the one who is making assumptions - maybe it’s specific to your area that they try to get every penny. > [@Max\_S](#): > > I’m skeptical that it is billed as a “preventative” visit. MDs usually don’t throw money away ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [July 15, 2024, 5:35pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/236 "2024-07-15T17:35:47Z")
I also cited an insurer from OP’s state. Evidently they get enough complaints about this that they put up a webpage explaining exactly as I’ve explained here. > [@Max\_S](#): > > Again, I don’t know what insurance you have. But most of our snowbirds from Massachusetts had BCBS MA. And the distinction between preventative and diagnostic is a long standing one that existed way back when I started. It is and has always been exactly as laid out here: > > [https://www.bluecrossmn.com/members/wellbeing/preventive-care/why-did-i-get-bill-preventive-care-visit](https://www.bluecrossmn.com/members/wellbeing/preventive-care/why-did-i-get-bill-preventive-care-visit) > **An office visit** > _You must pay for these services_ > > - Discussing or getting treatment for a specific health concern, condition or injury ETA: Just noticed that is for Minnesota, not Massachusetts. Here’s the explanation from Massachusetts BCBS: [https://provider.bluecrossma.com/ProviderHome/wcm/connect/bc1bb7fc-8759-4bb6-a9b7-23f41af4c61d/MPC\_031919-1R\_Preventive\_v\_diagnostic\_fact\_sheet.pdf](https://provider.bluecrossma.com/ProviderHome/wcm/connect/bc1bb7fc-8759-4bb6-a9b7-23f41af4c61d/MPC_031919-1R_Preventive_v_diagnostic_fact_sheet.pdf) > Preventive care includes services, such as checkups, screening tests, and immunizations. It’s care that you get when you’re symptom-free and have no reason to think you might be sick. > > Diagnostic care is what you have when you have symptoms of an illness or injury or are getting ongoing care for a condition. > > Diagnostic and preventive care may happen during the same visit > > […] > > Why it matters > In most cases, you don’t pay anything for preventive care. But you’ll have to pay something (copayment, deductible, or co-insurance) for diagnostic care, even if it happened during your routine health checkup. My insurance has $0 patient responsibility for PCP visits, regardless of whether it’s preventative or diagnostic. I specifically shopped for such a plan. OP evidently does not have that arrangement. ~Max ---
**Author:** ![Dr.Drake](https://avatars.discourse-cdn.com/v4/letter/d/ad7895/32.png) [@Dr.Drake](https://boards.straightdope.com/u/Dr.Drake)\ **Post date:** [July 15, 2024, 5:49pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/237 "2024-07-15T17:49:53Z")
Former American here. I never had anything serious to do with the medical system when I lived in the US, so I don’t know how it works. How much time do people spend dealing with the adminsitrative aspects of their medical care? I hear horror stories of patient spending hours on the phone with billing, writing letters, etc. Is it normal to have things mostly taken care of by insurance, or is it normal to spend hours going over everything, or something in between? ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [July 15, 2024, 6:00pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/238 "2024-07-15T18:00:08Z")
When I worked in medical most of our patients had some flavor of Medicare and did not have to worry about insurance issues in our office. But Medicare has its own problems when it comes to prescription drug coverage (though this was much improved by the time I stopped working) and I know it’s a huge headache when it comes to nursing care. Most insurers are no hassle at all so long as you stay perfectly healthy. If you need expensive treatment expect a hassle. Certain insurers, especially cheap ones, require a lot of patient and doctor involvement. We had a number of insurers whose premiums were markedly below competitors, they made up for this by requiring a pre-authorization process before any doctor except the PCP provides any medical service whatsoever. The worst is when they require the PCP to do the authorization, because then we have to bother the PCP all the time and he/she has better things to do. Most insurers I dealt with required prior authorization for the more expensive diagnostic tests such as CT or MRI. It’s a miracle routine mammograms and X-rays are a standard benefit now. This is handled by the doctor’s office and not normally transparent to the patient unless there’s a problem, but it can involve 20-60 minutes of administrative time just to convince the insurer that yes, the patient does in fact need the test done. To the patient this might mean waiting in the room for an hour or two or it might mean rescheduling for a test despite us having all the materials ready. Near the end of my time working however some insurers had started moving this process from semi-automated phone lines to online. ~Max ---
**Author:** ![doreen](https://avatars.discourse-cdn.com/v4/letter/d/858c86/32.png) [@doreen](https://boards.straightdope.com/u/doreen)\ **Post date:** [July 15, 2024, 6:05pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/239 "2024-07-15T18:05:04Z")
From your Minnestota cite > A preventive care visit is different from an office visit: > > - **The purpose of a preventive visit** is to review your overall health, identify risks and find out how to stay healthy. Your plan covers 100% of a preventive visit when you see a doctor in your plan network.\* > - **The purpose of an office visit** is to discuss or get treated for a specific health concern or condition. You may have to pay for the visit as part of your deductible, copay and/or coinsurance. > > **If you schedule a preventive care visit and ask your doctor about a specific health concern or condition, your clinic may code and bill the appointment as an office visit.** “If you schedule a preventive care visit and ask your doctor about a specific health concern or condition” is what it says - which doesn’t include the doctor asking me if I need refills or if I’m having any side effects from one of them or any of the other questions I get asked at every visit, preventative or not. In fact , the preventative visit actually involves a bit more work for the doctor as I don’t get a full exam when I see him every three months. That is clearly talking about a preventative visit where I say something like " I’ve seen some blood in my urine" or " This bruise is not healing" It takes some real twisting of words to consider sending a prescription refill for a condition I’ve had for years to be “diagnostic care” when “Certain blood tests to check such things as cholesterol or blood sugar” are apparently preventative. Aren’t you going to end up with a diagnosis if your cholesterol is too high? > [@Dr.Drake](#): > > How much time do people spend dealing with the adminsitrative aspects of their medical care? I hear horror stories of patient spending hours on the phone with billing, writing letters, etc. Is it normal to have things mostly taken care of by insurance, or is it normal to spend hours going over everything, or something in between? A lot of that is very individual - I might average one hour a year ( or less) dealing with billing or writing letters. Someone else with a different insurance company, different doctors ,different conditions, in a different state might spend more . I mention different states because different states have different laws - for example, if a network doctor draws blood and sends it to a non-participating lab, I’m only responsible for paying what I would pay a network provider. Pre- 2022. I would have probably spent a couple of hours on the phone trying to figure out why I got a bill and possibly trying to negotiate it down. ---
**Author:** ![Dr.Drake](https://avatars.discourse-cdn.com/v4/letter/d/ad7895/32.png) [@Dr.Drake](https://boards.straightdope.com/u/Dr.Drake)\ **Post date:** [July 15, 2024, 6:05pm UTC](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581/240 "2024-07-15T18:05:28Z")
From what my octogenarian father tells me, what is required of him just to sign up for care and choose a plan would not be possible for someone his age who wasn’t relatively healthy, educated, and computer literate. Or had children / friends / neighbours who were willing and able to help. [Previous page](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581.md?page=11) [Next page](https://boards.straightdope.com/t/another-pitting-of-the-us-health-care-system/968581.md?page=13)