I’ve been seeing my doctor pretty frequently lately in an attempt to tweak my blood pressure. Atenolol is no longer enough, so he has added first Losartan, then Amlodipine Besylate. Things seem better (Yay).
He has had me coming in every two weeks for a BP check, and suggests this continue. I have great insurance. Each visit has a small copay. Each visit lasts just a few minutes, and he gives me a thirty day supply of my meds (“samples”). Additionally there is a bar near his office that I like to visit after my appointment!
So, I’m not complaining. My visit copay is far less than what I would pay for the month supply of the three medications. My doctor is making out, I’m making out, but is my health insurance being cheated in any way?
My doctor is a friend. If I had to pay for each visit, I’d not bother, rather I’d check my own BP at the pharmacy. Just feels a little skeevy, but. . .
No, it would be insurance fraud if you just hung out or didn’t even go in to his office to see him, but he billed out for services anyway. Billing the insurance company for actual services rendered is… pretty much how it works. I don’t see any fraud unless he’s lying about whatever service was provided.
It’s not unusual to closely monitor BP while med changes are being adjusted. I don’t think your doctor is doing anything illegal or unethical. With capitation, he may not be getting all that much from your insurance company. And the cost for your care if you were to have a stroke would be so much more than the BP checks.
That makes more sense about the samples. If you’re worried about that part, it has nothing to do with your insurance. Samples are provided to the doctor by the drug company for that purpose. I had a doctor do the same for me when I had no insurance and was flat broke.
If the doctor is representing that something is medically necessary when in fact it’s not for the purpose of getting paid, that could be a problem. Presumably, though, he would say that it’s medically necessary to monitor your BP that frequently. Further, there probably isn’t an obligation to seek out the cheapest method, like having you go to the drugstore and then call it in, particularly since the accuracy of those readings (and potentially of a patient’s reporting) are likely to be much less reliable than checking it himself.
Like others have said, this isn’t fraud, and is probably good medicine (as long as it doens’t go on forever).
But one question: you say you have good insurance. Does it include mail-order prescription coverage? Mine does, and my BP and cholesterol prescriptions, because they are maintenance meds for potentially life-threatening conditions, carry zero copay for 90-day supplies, and are excluded from my deductible, to boot (I have a high-deductible-HSA plan). I thought this kind of benefit was pretty common.
I understand that 30 days at a time is probably right while you’re adjusting your dosages and such, but have you looked into mail order for when you’re stable?
Before I give an opinion, I would like to know the code he is using to bill. If he is using a CPT code of 99211 or maybe 99212 that’s fine. Anything higher then yes, he is defrauding the insurance company.
I have no idea, nor do I know how I’d determine that. I’ve done enough to feel comfortable at this point.
When I was only taking atenolol, I found a pharmacy in Canadia that would sell me as much as I wanted. I was buying four bottles of 100 at a time for the price of thirty tablets through a pharmacy. I’ll be looking into doing something similar when the need arises.
Sure, but that’s sort of gray-market. I was talking about a mail-order pharmacy on your health insurances prescription plan. If you don’t get prescription benefits at all, that’s one thing. But every plan I’ve had from an employer for at least the past decade had a pharmacy benefit that allowed for cheaper (and 90 day rather than 30 day) scrips, especially for maintenance meds, from a US mail-order pharmacy (currently using Express Scripts).
