Author Topic: $900 medical bill for a consultation - is this outrageous?  (Read 28982 times)

Jack

  • Magnum Stache
  • ******
  • Posts: 4734
  • Location: Atlanta, GA
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #100 on: August 12, 2015, 07:41:27 AM »
<foam>

You know, in every other professional career that I know of  -- accounting, engineering, law, etc. -- we have the equivalent of "residencies" too, except we don't need any weird-ass "national matching system." ...

In Canada, the monopoly on the practice of law rests in each province with a provincial body called the "Law Society". In order to join the Law Society of a province, every Society requires that the prospective lawyer spend a certain period of time "articling" under a lawyer or judge, essentially a mandatory apprenticeship, similar to the doctoral residency scheme. This is a matter of provincial law, so the rules are different in every province, but every province has some form of mandatory articling system.

And in order to get a Professional Engineer license, an Engineer-In-Training has to spend a certain period of time working under the supervision of a PE. That's not the problem. The problem would be if you artificially restricted which EITs (and how many of them) were allowed to work under which PEs using a centralized bureaucracy controlled by people with a vested interest in limiting supply of PEs.

</foam>

Cathy

  • Handlebar Stache
  • *****
  • Posts: 1046
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #101 on: August 12, 2015, 08:47:48 AM »
...a centralized bureaucracy controlled by people with a vested interest in limiting supply of [members of the profession]...

According to Judge Posner, the quoted description is basically the point of all professional organisations and is not unique to medicine. See Posner (1993) (noting that "so long as the number of lawyers is limited some lawyers, at least, will enjoy monopoly returns" (emphasis in original)). At page 15, Posner J seems to mention articling as an example of a system that, according to the article, may have an even stronger monopoly effect than the US system, so he seems to think it is relevant.
« Last Edit: August 12, 2015, 08:55:07 AM by Cathy »

Jack

  • Magnum Stache
  • ******
  • Posts: 4734
  • Location: Atlanta, GA
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #102 on: August 12, 2015, 12:22:41 PM »
<foam>

...a centralized bureaucracy controlled by people with a vested interest in limiting supply of [members of the profession]...

According to Judge Posner, the quoted description is basically the point of all professional organisations and is not unique to medicine. See Posner (1993) (noting that "so long as the number of lawyers is limited some lawyers, at least, will enjoy monopoly returns" (emphasis in original)). At page 15, Posner J seems to mention articling as an example of a system that, according to the article, may have an even stronger monopoly effect than the US system, so he seems to think it is relevant.

Okay, in that case maybe the legal profession has a problem too, then.

(I still don't think engineering does, since even though organizations like ASCE exist they don't seem to have much power to restrict the supply of engineers. If they did, you might expect software engineering -- which is completely unrestricted -- to have lower pay than other forms of engineering, but it doesn't.)

</foam>

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #103 on: August 12, 2015, 12:51:21 PM »
<foam>

...a centralized bureaucracy controlled by people with a vested interest in limiting supply of [members of the profession]...

According to Judge Posner, the quoted description is basically the point of all professional organisations and is not unique to medicine. See Posner (1993) (noting that "so long as the number of lawyers is limited some lawyers, at least, will enjoy monopoly returns" (emphasis in original)). At page 15, Posner J seems to mention articling as an example of a system that, according to the article, may have an even stronger monopoly effect than the US system, so he seems to think it is relevant.

Okay, in that case maybe the legal profession has a problem too, then.

(I still don't think engineering does, since even though organizations like ASCE exist they don't seem to have much power to restrict the supply of engineers. If they did, you might expect software engineering -- which is completely unrestricted -- to have lower pay than other forms of engineering, but it doesn't.)

</foam>
If the implication of all these threads is that doctors are conspiring to create a monopoly and force up prices by limiting residency slots, I don't think there is any evidence for that position (please share if there is). I don't know of any major group of physicians that wants residency slots restricted.

I have zero love for the AMA, which has been on the wrong side of history many times.  But, even the AMA has been pushing to increase residency slots; congress has been unwilling to fund more positions. Teaching hospitals honestly have little political clout. I know you think there should be another way to fund residencies, but I don't know how you will convince patients or insurers to pay for that, and that is ultimately where the non-governmental funding for healthcare is from. I would love to hear an actual suggestion for an alternative, instead of the continual comparisons to engineering, which is completely different.

goatmom

  • Bristles
  • ***
  • Posts: 291
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #104 on: August 12, 2015, 01:32:15 PM »
Would increasing the number of residency slots lower the cost of healthcare?  Are there that many doctors sitting around that aren't able to find a residency?  I hear about residency slots going unfilled in certain specialties where they look to foreign grads to fill in.  Midlevels who don't have the extensive training that doctors get were supposed to help with rising healthcare costs - around here the NPs are not charging that much less than the MDs despite much less training.  Again, I have no clue what the answer is.  I don't think it is ok just not to pay your bill though because you think it is too high.  Why is that ok?  I would never do that at a restaurant or a bar or a beauty salon.  If I am worried about costs - for example for braces  - I get the cost estimates up front.  I have no problem with disputing the bill if you think there is an error.  No foam, I promise.  I am knee deep in this system and can't figure it out so I can understand how incredibly frustrating it must be.

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #105 on: August 12, 2015, 02:12:38 PM »
I don't think it is ok just not to pay your bill though because you think it is too high.  Why is that ok?  I would never do that at a restaurant or a bar or a beauty salon.  If I am worried about costs - for example for braces  - I get the cost estimates up front. 

When you eat at a restaurant they bring you a menu that has prices on it so you know what the price is before you order. The problem with the US is that you have no idea what the health care is going to cost you. Even if you try to find out ahead of time you are going to spend a lot of time and often going to either no answer or a wrong answer. Braces is a relatively simple thing to get a price for and the price is highly negotiable. But with much of health care you can't know what you'll need when you go in, and don't know who is there to provide that mystery service to you, and what they charge for the mystery service. And while braces and eating at a restaurant are both very optional purchases, it's unclear what health care is optional or how optional it is and what the consequences are of skipping that care.

Bettis

  • Stubble
  • **
  • Posts: 196
  • Location: MA
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #106 on: August 12, 2015, 02:51:28 PM »
Quick update - I called the number on the bill and nicely asked if the coder could review it as I didn't believe the code matched the services rendered.  The person on the phone said she would send it out today.  Hopefully I will hear back soon.  I barely have enough in my HSA right now to cover the whole $900 but I'm on a payment plan from when my son was born so it will get a bit tight.  Luckily last month I got $600 from my employer for good biometric numbers so that lessens the blow.

goatmom

  • Bristles
  • ***
  • Posts: 291
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #107 on: August 12, 2015, 04:49:59 PM »
Yes, but in this example the cost was for a consult.  I bet if you called that clinic they would give you the price for a consult.   People call where I work all the time and ask for the cost of different services and we tell them.  Yes, in an emergency or during a hospitalization all best are off.

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #108 on: August 12, 2015, 05:33:30 PM »
Yes, but in this example the cost was for a consult.  I bet if you called that clinic they would give you the price for a consult.   People call where I work all the time and ask for the cost of different services and we tell them.  Yes, in an emergency or during a hospitalization all best are off.

But they wouldn't have necessarily known that it'd be a level 4 consult requiring 2 physicians.

goatmom

  • Bristles
  • ***
  • Posts: 291
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #109 on: August 12, 2015, 09:01:10 PM »
That is a good question.  When I've gone to a specialist - I've had an appointment with a specific doctor.  I have never received a bill from the facility unless I was inpatient.  I could always and ask the cost of the appointment.  I to a consult at Columbia Neurology last year.  Expensive. yes.  But, I was prepared as I knew it was out of my crappy network and was going to end up paying out of pocket.

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #110 on: August 12, 2015, 09:14:42 PM »
Yes, but in this example the cost was for a consult.  I bet if you called that clinic they would give you the price for a consult.   People call where I work all the time and ask for the cost of different services and we tell them.  Yes, in an emergency or during a hospitalization all best are off.

But they wouldn't have necessarily known that it'd be a level 4 consult requiring 2 physicians.
The two physicians doesn't matter. You can't have 2 physicians in the same specialty, from the same group both bill in the same day.

Cathy

  • Handlebar Stache
  • *****
  • Posts: 1046
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #111 on: August 12, 2015, 09:44:42 PM »
If the implication of all these threads is that doctors are conspiring to create a monopoly and force up prices ..., I don't think there is any evidence for that position (please share if there is).

According to the cartel theory of professions described in Posner (1993), the state has created a monopoly on the practice of medicine by enacting laws that regulate who can legally practice medicine and vesting in a regulatory body the power to determine who should be granted such right. Under the cartel theory, there is no debate about whether a medical monopoly exists (because it does, according to the cartel theory). However, under the cartel theory, there is still a question of whether the medical monopoly is a good thing or not. As Posner J notes, "[e]conomists consider cartels in general a bad thing ... [b]ut cartels can have good effects as well".

Under a laissez-faire capitalist system, there would be no state-sanctioned regulatory bodies limiting who could practice medicine. That would be determined instead by the free market. There would probably still be regulators but they would be voluntary organisations and lack the power of state coercion. I express no opinion on whether that would be better or worse than the current system.
« Last Edit: August 12, 2015, 09:59:19 PM by Cathy »

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #112 on: August 12, 2015, 10:27:33 PM »
If the implication of all these threads is that doctors are conspiring to create a monopoly and force up prices ..., I don't think there is any evidence for that position (please share if there is).

According to the cartel theory of professions described in Posner (1993), the state has created a monopoly on the practice of medicine by enacting laws that regulate who can legally practice medicine and vesting in a regulatory body the power to determine who should be granted such right. Under the cartel theory, there is no debate about whether a medical monopoly exists (because it does, according to the cartel theory). However, under the cartel theory, there is still a question of whether the medical monopoly is a good thing or not. As Posner J notes, "[e]conomists consider cartels in general a bad thing ... [b]ut cartels can have good effects as well".

Under a laissez-faire capitalist system, there would be no state-sanctioned regulatory bodies limiting who could practice medicine. That would be determined instead by the free market. There would probably still be regulators but they would be voluntary organisations and lack the power of state coercion. I express no opinion on whether that would be better or worse than the current system.
Veering off topic, but if the medical profession was a very good monopoly, there is no way homeopathic remedies would be legal. Seriously, diluting a bit of duck liver x 10 to the 200th power (a dilution at which there isn't a single molecule from the original duck liver left) and selling it in a sugar pill as a flu remedy... And they have sold $20 million dollars worth of this specific pill. FDA can't even require that the homeopathic remedies are proven efficacious. They just have to appear in the homeopathic pharmacopeia of the U.S.

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #113 on: August 13, 2015, 08:37:04 AM »
If the implication of all these threads is that doctors are conspiring to create a monopoly and force up prices ..., I don't think there is any evidence for that position (please share if there is).

According to the cartel theory of professions described in Posner (1993), the state has created a monopoly on the practice of medicine by enacting laws that regulate who can legally practice medicine and vesting in a regulatory body the power to determine who should be granted such right. Under the cartel theory, there is no debate about whether a medical monopoly exists (because it does, according to the cartel theory). However, under the cartel theory, there is still a question of whether the medical monopoly is a good thing or not. As Posner J notes, "[e]conomists consider cartels in general a bad thing ... [b]ut cartels can have good effects as well".

Under a laissez-faire capitalist system, there would be no state-sanctioned regulatory bodies limiting who could practice medicine. That would be determined instead by the free market. There would probably still be regulators but they would be voluntary organisations and lack the power of state coercion. I express no opinion on whether that would be better or worse than the current system.
Veering off topic, but if the medical profession was a very good monopoly, there is no way homeopathic remedies would be legal. Seriously, diluting a bit of duck liver x 10 to the 200th power (a dilution at which there isn't a single molecule from the original duck liver left) and selling it in a sugar pill as a flu remedy... And they have sold $20 million dollars worth of this specific pill. FDA can't even require that the homeopathic remedies are proven efficacious. They just have to appear in the homeopathic pharmacopeia of the U.S.

Medicine has a pretty strong monopoly. Supplements are largely ineffective at treating almost anything, so they really aren't diverting funds from the medical industrial complex. If people actually have something wrong with them they will either end up in the medical system or will die. Some sugar pills aren't going to help anything. Your argument would have been better if you referred to OTC meds like aspirin. Even so, that's a very small revenue loss compared to the gigantic amount spent on the medical system.

gbbi_977

  • Stubble
  • **
  • Posts: 102
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #114 on: August 13, 2015, 08:39:55 AM »
Yes, but in this example the cost was for a consult.  I bet if you called that clinic they would give you the price for a consult.   People call where I work all the time and ask for the cost of different services and we tell them.  Yes, in an emergency or during a hospitalization all best are off.

respectfully, I'm not sure that's true based on my experiences. When I had to see a specialist (I pasted the thread upthread - 'How to dispute a US doctor's bill') I rang in advance, because as someone else mentioned (or at least implied with the menu-in-advance analogy), I think I have a right to know in advance what I'm going to be charged. I can't do anything about the high cost of health care in this country, and I recognize that for me it's a 'first world problem' in that I'm able to afford to pay it either way, but I still just want to know - it's the principle, dammit! :)

And I was told it could be anywhere from $100 to $600, depending on how it was coded, and that there was no way of knowing the complexity of the visit in advance.

As I summarized in my other thread, they decided it was Level IV, and I (like the OP here) strongly disagreed that what I had received matched the description of Level IV. Many other Mustachians told me that they thought Level IV was a fair characterization, but when I got it reviewed after speaking to the nurse (who asked the doctor for permission for the bill specialist to recheck) they decided on second glance that it was Level III, knocking my $273 bill down to $121.

What frustrates me so much is just how opaque the whole system is, and how subjective these coding decisions seem to be, and how *of course* they are always going to err on the side of the higher/more expensive code, and in most cases we have no recourse.

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #115 on: August 13, 2015, 09:02:51 AM »
Yes, but in this example the cost was for a consult.  I bet if you called that clinic they would give you the price for a consult.   People call where I work all the time and ask for the cost of different services and we tell them.  Yes, in an emergency or during a hospitalization all best are off.

respectfully, I'm not sure that's true based on my experiences. When I had to see a specialist (I pasted the thread upthread - 'How to dispute a US doctor's bill') I rang in advance, because as someone else mentioned (or at least implied with the menu-in-advance analogy), I think I have a right to know in advance what I'm going to be charged. I can't do anything about the high cost of health care in this country, and I recognize that for me it's a 'first world problem' in that I'm able to afford to pay it either way, but I still just want to know - it's the principle, dammit! :)

And I was told it could be anywhere from $100 to $600, depending on how it was coded, and that there was no way of knowing the complexity of the visit in advance.

As I summarized in my other thread, they decided it was Level IV, and I (like the OP here) strongly disagreed that what I had received matched the description of Level IV. Many other Mustachians told me that they thought Level IV was a fair characterization, but when I got it reviewed after speaking to the nurse (who asked the doctor for permission for the bill specialist to recheck) they decided on second glance that it was Level III, knocking my $273 bill down to $121.

What frustrates me so much is just how opaque the whole system is, and how subjective these coding decisions seem to be, and how *of course* they are always going to err on the side of the higher/more expensive code, and in most cases we have no recourse.

All the coding is developed by the AMA. It's not surprising that it would provide the physicians with a great deal of flexibility.

But in fairness, the system is complicated partly because medicine is so complicated. It really can't be a free market for many reasons--one being that it's impossible to have perfect information among all participants.

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #116 on: August 13, 2015, 11:36:16 AM »
All the coding is developed by the AMA. It's not surprising that it would provide the physicians with a great deal of flexibility.

But in fairness, the system is complicated partly because medicine is so complicated. It really can't be a free market for many reasons--one being that it's impossible to have perfect information among all participants.
Any flexibility is more around determining what is appropriate care when you are seeing the patient - how much do you need to ask, examine, and work-up a given issue. Once you have done that and documented it, the appropriate level of billing isn't open to much interpretation. That said, it is just so damn complicated that it is easy to make mistakes when picking a code.

Here is an example of what the provider is supposed to be thinking about when determining the appropriate level for just the physical exam component of the visit (one out of the three components considered in choosing the right level of service to bill):

http://emuniversity.com/PhysicalExam.html
Quote
The physical exam is one of the three key components of E/M documentation. Similar to the levels of history, there are four levels of physical exam documentation:

1)    Problem Focused
2)    Expanded Problem Focused
3)    Detailed
4)    Comprehensive

E/M University Coding Tip: Unlike the key components of history and medical decision-making, the rules defining the various levels of physical exam are quite different for the 1995 vs. the 1997 E/M guidelines. The 1995 E/M guidelines allow the physician to complete the physical exam by documenting organ systems or body areas. This approach is quite subjective and gives physicians a lot of leeway and “wiggle room.” On the other hand, the 1997 E/M guidelines are quite rigid and force physicians to document the exam using specific bullets. The 1997 physical exam rules are much more “black and white”—either the bullets are there or they aren’t.

1997 Physical Exam Rules

General Multi-System Exam (for specialty exams, click here.)

For the purposes of documenting the physical exam, the 1997 E/M guidelines rely on the use of bullets from well defined organ systems:

1997 Problem Focused Exam

One to five bullets from one or more organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: CTA
CV: RRR, no MRGs

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)

Total bullets = four (although only one to five bullets are required)

1997 Expanded Problem Focused Exam

At least six bullets from any organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, nontender
Extremities: No peripheral edema

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for examination of the abdomen)
(1 bullet for examination of extremities for edema)

Total bullets = six

1997 Detailed Exam
At least two bullets from six organ systems OR 12 bullets from two or more organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time

(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)

Total bullets = 12

1997 Comprehensive Exam

Two bullets from EACH of nine organ systems

Example

Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA
HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations;
normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules
Psych: Appropriate affect, alert and oriented to person, place and time

Systems and Bullets

Constitutional
(1 bullet for three vital signs)
(1 bullet for general appearance)

Eyes
(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)

Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose—“atraumautic”)
(1 bullet for examination of oropharynx)

Neck
(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)

Respiratory
(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)

Cardiovascular
(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)

Gastrointestinal
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)

Lymphatic
(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)

Skin
(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)

Psychiatric
(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)

Total systems = 10 (although only nine are required)
Total bullets = 20 (although only 18 are required—two in EACH of nine systems)

E/M University Coding Tip: Although it may seem tedious at first, it is recommended that physicians use the 1997 bullet points when quantifying the physical exam. The best approach is to review the organ systems and bullets and construct a pre-set template for each level of exam. This will ensure optimal compliance with the somewhat arbitrary rules for documenting the exam.

Organ Systems

The 1997 E/M guidelines recognize the following organ systems:

1. Constitutional
2. Eyes
3. Ears, nose, mouth and throat
4. Neck
5. Respiratory
6. Cardiovascular
7. Chest (breasts)
8. Gastrointestinal (abdomen)
9. Genitourinary (male)
10.Genitourinary (female)
11. Lymphatic
12. Musculoskeletal
13. Skin
14. Neurologic
15. Psychiatric

Physical Exam Bullets

Constitutional

    1)   Three vital signs
   2)    General appearance

Eyes

    1)   Inspection of conjunctivae and lids
    2)   Examination of pupils and irises (PERRLA)
    3)   Ophthalmoscopic discs and posterior segments

Ears, Nose, Mouth, and Throat

    1)   External appearance of the ears and nose (overall appearance, scars, lesions, masses)
    2)   Otoscopic examination of the external auditory canals and tympanic membranes
    3)   Assessment of hearing
    4)   Inspection of nasal mucosa, septum and turbinates
    5)   Inspection of lips, teeth and gums
    6)   Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx


Neck

    1)   Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
    2)   Examination of thyroid

Respiratory

    1)   Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
    2)   Percussion of chest (e.g., dullness, flatness, hyperresonance)
    3)   Palpation of chest (e.g., tactile fremitus)
    4)   Auscultation of the lungs

Cardiovascular

    1)   Palpation of the heart (location, size, thrills)
    2)   Auscultation of the heart with notation of abnormal sounds and murmurs
    3)    Assessment of lower extremities for edema and/or varicosities
    4)   Examination of the carotid arteries (e.g., pulse amplitude, bruits)
    5)   Examination of abdominal aorta (e.g., size, bruits)
    6)   Examination of the femoral arteries (e.g., pulse amplitude, bruits)
    7)    Examination of the pedal pulses (e.g., pulse amplitude)

Chest (Breasts)

    1)   Inspection of the breasts (e.g., symmetry, nipple discharge)
    2)   Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)

Gastrointestinal (Abdomen)

    1)   Examination of the abdomen with notation of presence of masses or tenderness
    2)   Examination of the liver and spleen
    3)   Examination for the presence or absence of hernias
    4)   Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids,
           rectal masses
    5)   Obtain stool for occult blood testing when indicated

Genitourinary (Male)

    1)    Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)
    2)   Examination of the penis
    1)   Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness)

Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures, which may include:

    1)   Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)
    2)   Examination of the urethra (e.g., masses, tenderness, scarring)
    3)    Examination of the bladder (e.g., fullness, masses, tenderness)
    4)   Examination of the cervix (e.g., general appearance, discharge, lesions)
    5)   Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
    6)    Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

Lymphatic

Palpation of lymph nodes two or more areas:

    1)   Neck
    2)    Axillae
    3)    Groin
    4)   Other

Musculoskeletal

    1)   Examination of gait and station
    2)   Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia,           infections, nodes)

Examination of the joints, bones, and muscles of one or more of the following six areas:

    a)   head and neck
    b)    spine, ribs, and pelvis
    c)    right upper extremity
    d)   left upper extremity
    e)   right lower extremity
    f)    left lower extremity

The examination of a given area may include:

 1)   Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation,
 2)   defects, tenderness, masses or effusions
3)   Assessment of range of motion with notation of any pain, crepitation or contracture
 4)  Assessment of stability with notation of any dislocation, subluxation, or laxity
 5)  Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any  atrophy or abnormal movements

Skin

    1)   Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
   2)   Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

Neurologic

    1)    Test cranial nerves with notation of any deficits
    2)   Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)
    3)   Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

    1)   Description of patient’s judgment and insight

Brief assessment of mental status which may include

   1)   orientation to time, place, and person
   2)   recent and remote memory
   3)   mood and affect


That massive wall of crap is part of the reason docs complain so much about all of the paperwork and hassle involved in practicing medicine. None of that helps actually provide care to the patient, but that is a small part of what is required for documentation and billing - multiplied by 25+ patients per day.

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #117 on: August 13, 2015, 12:05:24 PM »
I don't think it is ok just not to pay your bill though because you think it is too high.  Why is that ok?  I would never do that at a restaurant or a bar or a beauty salon.  If I am worried about costs - for example for braces  - I get the cost estimates up front. 

When you eat at a restaurant they bring you a menu that has prices on it so you know what the price is before you order. The problem with the US is that you have no idea what the health care is going to cost you. Even if you try to find out ahead of time you are going to spend a lot of time and often going to either no answer or a wrong answer. Braces is a relatively simple thing to get a price for and the price is highly negotiable. But with much of health care you can't know what you'll need when you go in, and don't know who is there to provide that mystery service to you, and what they charge for the mystery service. And while braces and eating at a restaurant are both very optional purchases, it's unclear what health care is optional or how optional it is and what the consequences are of skipping that care.

An anecdote from yesterday:

DW is pregnant and we have previously identified all the costs associated with pregnancy, and even picked a health plan prior to conceiving that would be best for pregnancy in our estimation given the providers we wanted to use. We also identified (as best we could) all the copays we'd have along the way. For her visit last month she wasn't supposed to be charged (we thought). So there was no request for copay when she was there. Then we got an EOB from the insurer saying we owed $50. Then she asked the provider about it and they said to wait until they sent us a bill. And then they sent us a bill--PAST DUE. OK... So then we go in the next day (yesterday) for the next regular visit and try to pay it. Then the provider says to let them check on it and then they tell us that we don't actually owe anything and said something about having to bill things that way. I don't understand at all what happened. But this silliness is just a trivial example of how you never know what to expect. And lots of time and mail and phone calls get consumed on top of it all. We can easily afford the $50. But not everyone can be as cavalier about medical bills (like the $900 that started the thread).

justajane

  • Handlebar Stache
  • *****
  • Posts: 2147
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #118 on: August 13, 2015, 01:18:45 PM »
We got a $300 ultrasound bill over 12 months from the date of service. And we'd already paid the hospital once before. This was tacked on after we had already paid. Um, no. It's still in arbitration, and UHC is fighting on our behalf. Apparently the hospital violated their contract with the insurer by billing us for that.

Edited to add this was an 2 second ultrasound with an ultrasound machine that looked like it was 25 years old. The were just checking to see if the baby was still breech.
« Last Edit: August 13, 2015, 01:20:26 PM by justajane »

gbbi_977

  • Stubble
  • **
  • Posts: 102
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #119 on: August 14, 2015, 10:03:11 AM »
To the OP -  I know I already posted a link to this but I think you should read tis thread: http://forum.mrmoneymustache.com/ask-a-mustachian/us-how-to-dispute-a-doctor's-bill/

The people who replied had great advice, which boiled down to (i) speak to clinical staff, NOT billing staff, because coding is a clinical decision - billing staff can only check you were charged what you should have been charged for that level (forum members, correct me if I'm wrong) and (ii) be very friendly and polite.

It worked for me - my Level IV visit ($273) got downgraded to Level II ($121)