And then if you are perfectly healthy you don’t need insurance. (If only that were always possible.)
Is you father in the US ? If so, he’s probably talking about Medicare supplements /Medicare advantage. Which can be pretty confusing if you are like my octogenarian mother and want “the best” without necessarily understanding that what is the best for a snowbird who spends half their time in Florida is not necessarily the best for someone who lives in NY all year. The last time we had to help her choose, charging more than Medicare would pay was allowed in some places, but not in NY and it took some effort to convince her she didn’t need a supplement that covered that.
Yes, you are. High cholesterol is a specific instance of diagnostic care mentioned in the BCBS Massachusetts PDF I linked to. Compare, especially, with the diabetes example.
Preventative and diagnostic
Examples What You Pay Frank was diagnosed with high cholesterol last year. He went to see his doctor for a routine health checkup. During the visit, his doctor also discussed his diet and medication, reviewed possible side-effects he could have from the medicine, and ordered lab work (lipid panel) to monitor his condition. If your plan covers preventive care at no cost, you’ll pay nothing for your routine health checkup. Your doctor will bill you (copayment, deductible, or co-insurance depending on your plan) for assessing your condition and for the cholesterol test (lipid panel). Sally has diabetes and at her routine health checkup, her doctor ordered an A1C test to check her blood sugar. You will have to pay something for your doctor’s time assessing your condition and for the A1C lab test.
Before a doctor renews a treatment plan he or she is supposed to assess (or re-assess) the patient’s condition. That is what is being billed - evaluation and management of new/existing disease, as distinguished from evaluation and management to prevent disease.
~Max
Yes, and yes, it’s the Medicare supplements. He seems to understand it, and gets good care, which are the main things. It just seems needlessly complicated.
For some reason, I can no longer open that document you linked but I believe that was the document where screening tests such as those to check cholesterol or blood sugar were listed as at least possibly “preventative”. They are obviously not “preventative” when you have already been diagnosed. What I mean is say I have no symptoms or history , but those tests are given to me anyway at a preventative visit. The results show that my cholesterol is high. At that point, I get diagnosed , don’t I ? And testing me prevented nothing. So how is it that a test that prevented nothing but resulted in a diagnosis “preventative” rather than “diagnostic” ? that’s what I mean about twisting words.
No. There is a certain threshold before high cholesterol is diagnosed as such and often managed with medication. The point of a standard preventative cholesterol test is to alert the physician before you reach that threshold, so he or she can advise you to make lifestyle changes to prevent the disease in the first place. Likewise with high blood pressure, high glucose/prediabetes, etc. A single spike does not necessarily mean you get diagnosed with chronic disease.
~Max
I think the issue is that high cholesterol is not a disease. Sure, people who have high cholesterol have a high incidence of heart disease, but high cholesterol is not, in itself, the disease. The drugs administered to lower ones cholesterol are, in fact, preventative, as there are plenty of studies that show that lowering cholesterol reduces the likelihood of developing heart disease.
About a decade ago, my mother-in-law slipped and fell during a trip to Las Vegas, breaking her leg and requiring a week-long hospital stay. Now, she had travel insurance that covered everything, but for years afterwards the hospital would regularly send her letters demanding payment for God knows what. The first couple of times she referred them to the insurer, but they just wouldn’t stop. I told her to just ignore them - it’s not like they could do anything to her, after all - but the bastards really stressed the poor women out. It took them the better part of 7 years to stop pestering her.
On the one hand, when i asked my doctor what a flu shot would cost, he had no idea. On the other hand, when i email my doctor and tell him i would like to try estrogen for menopause related symptoms, he told me what the options were and suggested a line of treatment and sent in a prescription without charging me. (Also when i emailed him to say i tested positive for covid, and various other medical conditions that have come up.) He’s told me that he chose to be an employee at a large hospital, and not have an independent practice, because he doesn’t want to have to deal with billing and knowing that stuff.
He does charge me when i show up in person. But my annual physical is always billed as a routine physical, no matter what we discuss and no matter what he ends up prescribing. I do get billed for blood tests, but not for “managing ongoing conditions”.
It’s like saying that a concussion is a medical condition. Getting hit in the head is not a medical condition, it’s what leads to a medical condition.
Just as high cholesterol is what leads to a medical condition, but is itself not a medical condition.
This makes perfect sense to me.
You fucking idiot, every year I go through this. Sometimes multiple times a year. They always back down, because unlike you, they aren’t going to fuck with the regulators. They are just betting that many people will just be bamboozled by scumbags like you.
I don’t see why you’re blaming @Max_S for all the ills of American healthcare. I appreciate him for providing an insider perspective.
He’s pretending as if “up coding” is normal and ethical. It is not. It’s fraud.
Did you read his thousand word libertarian manifesto about how we “choose” our health insurance plans and how we can just get better plans by paying tens of thousands of dollars for plans with deductibles in the tens of thousands?
This is no more inside information than telling us how he deletes security video when he’s buggering little boys.
I can’t pick my insurance, but i can pick my doctors, etc. and i used to have a dentist who did a lot of upcharging. He didn’t understand why i cared, because he only billed the insurance company, not me. But i thought it was petty fraud, and found a new dentist.
Most of us can’t pick our doctors because there’s a waiting list years long for a PCP in the one, two or three networks that our employers provide.
I’ve had the same doctor for over a decade, and until three years ago we never had these issues. Not coincidentally the physicians group with hundreds of doctors he was in was acquired by a group that has thousands of doctors.
I’m pretty sure the extra billings the “practice management” consultants are generating is going right into the pockets of the hardworking PCPs who are now seeing more patients per hour /s
I was replying to doreen, who seemed to be unclear as to the difference between a “preventative” and “diagnostic” procedure. As they could not be specific, I am assuming they meant whether or not a procedure (in this case, a blood test) was a screening tool or diagnostic, and why, once high cholesterol is identified, why is the procedure considered preventative when it did not prevent the high cholesterol.
High cholesterol is definitely a medical condition. It, in itself, isn’t fatal. It can lead to heart disease, however, which can be prevented by adjusting diet and/or medication. So, the procedure (blood test) is a screening test to identify those people for whom a cholesterol-lowering regimen may be beneficial in preventing heart disease.
The reason any of this matters is that the ACA, I believe, requires insurance to cover certain screening procedures at 100% with no deductible while diagnostic procedures are subject to plan coverage (typically 80% after deductible has been satisfied). Take X-rays for example. An X-ray as a screening procedure for breast cancer is a well-known and widely used procedure. Using an X-ray to diagnose a damaged ankle is also well-known and widely used, but is purely diagnostic. So, if you have a high-deductible plan and haven’t satisfied the deductible, you could be charged the full amount for an X-ray if you badly twisted your ankle while a breast X-ray wouldn’t cost a cent (assuming you are in the target demographic).
The endoscopy center tried to say that my colonoscopies aren’t screening because my FATHER had colon cancer 30 years ago.
Whoosh??
Around here (DC metro), it’s certainly POSSIBLE to find a PCP, but not always EASY. Some are not taking new patients. Some have gone concierge (I had 2 in a row do that).
I’m sure it’s worse in other parts of the country.
And the oft-quoted caution that during your screening colonoscopy, if they find a polyp, it suddenly becomes diagnostic and subject to full costs. I have not encountered that myself (well, none of mine are screening any more) but I believe it does happen.
Both of your posts are very insightful.
I think the “upcharging”, as you call it, is legit, if you are referring to charging for procedures not covered or charging more for the procedure than the plan covers. These charges get refused by the insurance and you are only billed for what the plan says and what the dentist has agreed to.
I believe the reason they do this is because the insurance rates are based on “usual and customary” fees and procedures. I also believe this is old-school. That is, the insurance companies are wise to this trick. Their plans now pay what the providers agree to, regardless what the providers charge. But, apparently, the providers figure upcharging can’t hurt and it may end up increasing what the plans are willing to pay.
Also, there may also be an effect that part of the plan the provider has agreed to requires their billing to be X% higher than what the plan provides, so that the patient sees that the insurance “saved” them and scares them into keeping the insurance.