Another pitting of the US health ”care” system

The BBQ Pit
261

The mammogram example is triggering to me. Insurance pays 100% for a screening mammogram but not a diagnostic mammogram. If I do an examination and find a mass I have to order a diagnostic mammogram. I explain to the patient that they may have a copay and deductible. I invariably get a call back saying that I ordered the wrong test and the patient wants a screening mammogram because it is fully covered and I have to explain again that they need a diagnostic mammogram because there is an issue. The next call is from the X-ray facility telling me that I coded wrong because the patient told them they want a screening mammogram so I have to explain why that is not appropriate. Meanwhile, the facility calls me about a screening mammogram I ordered but the patient is complaining of breast pain so could I please reorder it now this second because the patient is there waiting. Then when the patient gets the bill they call me angry because I ordered the wrong test.

I do not get paid for any of this.

262

Upcoding is neither normal nor ethical. As you say, it is a form of fraud and it is illegal. However, it is not fraudulent (or upcoding) if your doctor actually reviewed and renewed a treatment plan for chronic disease, and billed 9921X instead of or in addition to 9939X. However, something like billing a level 5 visit when only a level 4 is warranted would be classic upcoding.

I think most docs determine level by time spent. 30 minutes for level 4, 40 minutes for level 5. Not just time in the room but including records review and charting. This is how most everybody does it in practice but for a long time you were supposed to bill by complexity. Complexity is still an option. The more that’s going on with you, and this specifically includes stable chronic conditions, medical records, and prescriptions, the more the visit costs. A level five visit might be twice as expensive as a level two visit. An example of a level 2 visit would be maybe 20 minutes dealing with one low risk problem like a cough, no extra records or chronic conditions to review. A thirty or forty minute visit where the patient has two stable chronic conditions, routine labs or records to review, and a prescription refill would be level 4. But if one of your conditions is getting out of hand, and it is a serious threat to your health, that could bump it up to level 5.

This is of course exclusive to diagnostic care. Preventative care coding does not have guidelines based on managing chronic diseases because that is, by definition, not preventative care. Preventative care lacks a chief complaint, and levels (for the visit itself) are based on the patient’s age I think.

You mentioned upthread that the cost of a visit went up over the years - that is true, but… in eight years the price of an office visit where I worked, and these were across the board in our region: Medicare fees for 99214 from 2015 to 2019 was about $100-$110 as I recall. With COVID-19 it jumped to $125 and I think it’s still there now. These are regional numbers though - in my case the region is all of Florida except Miami and Fort Lauderdale. These are Medicare numbers of course, but as I explained above my experience working in Florida - it may be different for other regions or specialties - most of the pricing reflected Medicare fees. Some insurers were lower (i.e. Medicaid, VA) and most were higher, usually around 1.2-1.5x, but I don’t recall any significant price changes disproportionate to Medicare.

In fact I looked up the Medicare prices in Massachusetts and even a 99205 is not anywhere near $550. It’s roughly half of that and that’s the most expensive scenario, 60+ minutes spent on a new patient. This is the base rate I’m talking about. I don’t doubt your bill but I do wonder if your insurance is just really bad, or if private insurance is just way higher than Medicare in your area, or if that number includes other services not mentioned, or if your docs are doing some “creative” billing you haven’t told us about. Because I would not expect the allowed amount for a visit to be so high.

I also want to reiterate that I still do not understand how your responsibility is 80% of the bill. Unless this bill meets your deductible or OOP max, it makes no sense.

~Max

263

My last symptoms of “chronic disease” that I’m being “reviewed and renewed a treatment plan for” was in the 1990s. I have taken the same medication for it for over twenty years. It’s not a disease, it’s a condition. Again, when I complain, eventually it is recoded. Because they know very well that what they are doing is fraud. If you ask my doctor if this was a routine annual physical he will say it was. It’s the folks like you going back and looking at the notes and history and saying “I can recode this as something else generate another $300 in billing and maybe they’ll just pay it. If they complain too much or involve the Dept of Insurance we can just recode it, no harm, no foul. My boss will be chuffed!”

If I had a skin tag removed in 1995 and it was biopsies and and came back negative, am I going to never have a covered physical again if my doctor asks me if I noticed any new moles, patches or changes in my skin? Because my doctor asks me this every single time I have a physical.

You seem to be positing a situation where no one who’s ever had anything that MIGHT have some ongoing impact can EVER have a routine physical.

264

I’m saying people are doing all kinds of bad things.

Your response is that unless people are doing all kinds of bad things, what you’re reporting is implausible. No shit Sherlock.

What I’m complaining about is that we have a Heath “Care” system that attracts bad actors like shit attracts flies. You’re explaining very carefully that flies do what flies do.

265

When my daughter was a wee lass, her pediatrician was a personal friend of mine. Being friends, we did what we could to help each other out.

The pediatrician was part of a group practice, so in some ways his hands were tied. But every time I brought her in for whatever, he coded the visit as an ear recheck, which was “free” for me (no copay).

One time I brought her in for an illness of some sort. My friend was on vacation, so we saw someone else. He kept looking at her chart and talking about her chronic ear problems. I was a bit nervous, but it turned out he was just messing with me, as he knew all about our arrangement. Our visit was coded as an ear recheck

266

I get so mad about this. My husbands doctor really pushed Cologuard, because insurance would far rather pay for that. So of course when it came back positive, we had to schedule a diagnostic colonscopy and pay for that.

Worse, because of shennanigans with referrals and scheduling, the colonoscopy took months. By the time that was over and we scheduled the surgery that was needed, he had a handful of cancer cells in on of his many polyps. If it had been another month or two, we might have been in real trouble. We may still be.

267

Max_S is a very strange person. Arguing with him is like arguing with a robot suffering from some sort of myopic fixation. You tell him that it hurts to have dice shot at your head, and he responds condescendingly that dice are cubes with six faces, eight corners, and twelve edges. You reply, obviously that’s the definition of a cube, but the point is that it’s painful when they’re flung into your skull. He then comes back to insist that not only do the cubes hitting you have eight corners, twelve edges, and six faces, but in fact all cubes have twelve edges, six faces, and eight corners, and here’s five hundred words of geometric proof to that effect. And around and around you will go. I respect your doggedness in trying to get him to wake up to what you’re saying, but many before you have failed in the attempt.

268

Chronic disease is a disease, by definition. I’m not sure what you’re trying to say there. If a condition lasts twenty years it is a chronic disease, also by definition. Diseases do not always manifest symptoms, especially when well managed. You say you’re still being treated for this disease, by your PCP (who prescribes the medication). As I mentioned upthread, a physician is ethically obligated to re-evaluate your disease on a regular basis, usually annually, if he or she is authorizing continued treatment. The physician’s job is not to rubber stamp refill requests. That you haven’t had any symptoms in 20 years with the same prescription is the second-best case scenario, after a cure.

A routine annual visit does not imply preventative care to the exclusion of diagnostic care. A routine annual visit may include diagnostic care, preventative care, either, or both. A “routine physical exam” or “routine annual physical” could refer to a preventative care visit, the routine nature of the physical implying lack of a diagnosed problem. But “the physical” exam also refers specifically to the portion of the appointment where the physician (and support staff) examines your body - pulse, bp, height, weight, stethoscope, lymph nodes, etc; or to the mandatory section of every office note where those results are recorded. And the “routine annual physical” also refers specifically to the routine annual PCP appointment where this physical exam usually takes place. A routine annual physical, depending on the definition, could or couldn’t have problem codes and E&M codes.

The bottom line here is that the language on annual PCP visits is not used consistently so it is confusing. If you aren’t in the business, when a Medicare patient sees his or her primary care once a year, you might call that visit a routine physical. From a billing standpoint, no Medicare patients ever have “routine physicals” because Medicare does not cover routine physicals. Medicare has its own preventative care scheme and they are called annual wellness visits, which are different than routine physicals and notably doesn’t include bloodwork. AWVs are covered 100% by Medicare. Routine physicals are 100% billed to the patient under Medicare but may be covered by supplementary plans. Routine physicals in that sense are 100% covered by ACA plans, but that kind of visit is not necessarily implied when someone says routine annual physical, annual physical, yearly check-up, etc.

The healthcare system operates on the assumption everyone understands all of this, of course.

~Max

269

The difference is after a few repeated prompts, I’d expect the algorithm to start giving different, albeit often bizarre responses, as it learns it is not providing what is desired.

Modern AI bots interact with human beings much more ably than Max appears capable of

270

Don’t be silly. Not all dice are cubes.

That was a joke, I didn’t miss your main point. I’ve acknowledged many times that the U.S. health care system sucks.

~Max

271

Now I’m trying to figure out which D&D dice would hurt the most if they were shot at your head. You’d think that it would be the D4, because of the pointiness, but I thing that aerodynamics have to play a role here, and that a D4 would tumble and lose a lot of energy before they hit you, even if you could be sure that the pointy bit hit you first (with a triangular barrel, maybe?). In fact, I’d bet the most damaging die would be the D20, on account of it being the closest to an old-fashioned musket ball. I suppose it depends on the range.

Is being shot by a polyhedron covered by insurance?

272

I’d guess a D8. It’s very pointy but there are a lot of points staggered at irregular intervals so you’re more likely to be hit by a point. With a D4 and a D6 you’re probably more likely to be hit by a flat side than a point. And anything higher than a D8 isn’t pointy enough.

I think a D8 hits the sweet spot of maximum damage potential, especially the ones that don’t have rounded points.

I have probably given this subject far more credit than it warrants.

273

The healthcare system operates under the assumption that enough people are fools like you to keep it going until it totally destroys our society.

Kinda like the defenders of the Fugitive Slave Act. Which I’m sure you’d defend to the death.

274

I don’t get the sense that Max:S is defending the US healthcare system, more like trying to explain it. Which is virtually impossible and ridiculously confusing, apparently by design. I’ve been there. Hated it. Hated it very much. Our employer family plan was based in the midwest. We were in NE. Nothing was “in network”. Nothing! Everything had to be paid out of pocket and then submitted for “reimbursement” Hahahahah. Hospital? Nope. ER? Nope. PCP? Nope.

Since then I’ve lived in the UK and now Canada. Have yet to see a bill for anything except physio or massages or the occasional drug. We do have supplementary insurance for that stuff.

275

Agreed and I do appreciate it somewhat.

Though there is still a bit of a “Let them eat cake” vibe in some of the responses.

276

There’s also, “That’s not legal, so I can’t understand how this could be happening. You must be leaving important, relevant stuff out.”

277

Just addressing this one line: presumably if something DOES go through as preventative, the doctor is paid anyway. Amounts may differ, and maybe the reimbursement is better if it’s NOT preventive.

I’ll be a bit of a devil’s advocate on US versus Canada: I was at a gathering of friends a few weeks back, where several of the people were from major metropolitan areas in Canada, and both said they had a years-long wait to be assigned a primary care doc (something that a Quebec-based Doper has also mentioned).

And from another friend: her husband had to wait 4-5 months for elective surgery.

Whereas around here, it’s generally possible to find a new primary care doc (though some don’t accept new patients, or have gone concierge), and when I needed to bid adieu to my gallbladder, I could have had it done within 2 weeks or so.

Of course, these examples are artifacts of the US system having too much capacity, and some aspects of Canada having too little. Elective surgery can certainly be postponed (My gallbladder could have remained in residence a bit longer, for sure) which gives points to Canada; primary care shortage is risky (as someone with numerous chronic health conditions, that’s frightening).

But the concept of NOT risking bankruptcy from a sudden illness has rather a lot of appeal; two different family members had that happen to them.

Medicare will, I hope, be marginally better, as a sort of single payer system, but then there’s that Medigap stuff layered on the top, which can REALLY lock you into a plan.

278

And also that those who don’t can be billed (bilked) for some more cash.

30ish years back, I saw a doctor for what turned out to be nothing. He HAD to put some kind of diagnosis on the paperwork, or insurance might not have paid anything. So, IIRC, he put down the condition they were checking me to rule out. At least there’s less of THAT bullshit now.

Luckily (?) for me, I have enough chronic conditions that there will always be something to diagnose. I honestly don’t think any office visit has been billed as preventive, except the (not as annual as it should be) well-woman check.

279

Standard practice is to codify the complaint if diagnostics are done. For example, if you complain of a sinus infection the proper code for an X-ray is that of sinus infection, even though the X-ray itself is being ordered to rule out an infection. However I will note that standard chest X-ray for a cough is billed under a cough and not i.e. suspected pulmonary diseases. In that case the symptom complained of (cough) has its own specific problem code, whereas to my knowledge there is no specific code for suspected sinus infection, only sinus infection.

~Max

280

Yeah - in my case, I think they wanted to rule out adrenal suppression or something like that. And that was the documented diagnosis on the claim form. Yeesh.