Author Topic: US - how to dispute a doctor's bill?  (Read 13371 times)

gbbi_977

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US - how to dispute a doctor's bill?
« on: July 14, 2015, 09:01:14 AM »
Hey everyone,

I'm an Aussie, happily married to a Michigander and living in the States. I'm trying to navigate the healthcare system.

I was recently back in Australia, got a general check-up (they're free there) and my doctor found a small breast lump - she recommended an ultrasound, I got an ultrasound same day (also free) and the report said "everything appears benign, but due to your age a follow-up would not be unreasonable."

I was flying back to the States the next day and couldn't do the follow-up in Australia unfortunately, so went to a specialist in the US on my return.

I knew it would be expensive, I get that healthcare is high quality here (I don't think it's higher quality than Oz but that's another debate...) and we have insurance and can afford it and this wasn't an optional visit. But I was surprised when the bill came, after insurance adjustment, for $273.

You guys, I spent 10 minutes with the doctor. His nurse took a history, he did a manual exam and looked at the Australian images/reports. He agreed they were just cysts, and that I don't need to do any follow-up. Easy peasy.

So on the bill, it's been coded as a "Level IV" visit. I rang my insurer who read the description to me of a Level IV visit:
“New patient Level IV: office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: comprehensive history, comprehensive examination, medical decision-making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professions or agencies, are provided consistent with the nature of the problem and the patients and/or family needs. Usually presenting problems are moderate to high severity, typically 45 minutes are spent face to face with the patient and/or family."

I want to appeal their coding of the visit as Level IV. I can't see how confirming another doctor's diagnosis (benign) and doing a 10 minute face-to-face meets the Level IV description.

But I'm wondering if this is totally futile...obviuosly the doctor has all the power and he coded it as Level IV. Any tips/advice? Should I just let it go and pay the $273, even though I feel like I've been ripped off?

Midwestache

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Re: US - how to dispute a doctor's bill?
« Reply #1 on: July 14, 2015, 09:07:39 AM »
As a physician I would say that is pretty cheap for a visit. Let me start off by saying that just because he spent 10 minutes with you does not mean that is all he spent looking over your chart, going over your history, reviewing your images, reading other peoples reports. He may have even done a literature search to confirm their plan of action. Probably not for a cyst in the breast but there are many times I have to spend time doing research before speaking to a patient. Even though I only spend a "few minutes" with the patient I have spent much more time reading up on the patient and his or her history. $273, is not a rip off. I spend that much getting two tires changed on my car.


Merrie

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Re: US - how to dispute a doctor's bill?
« Reply #2 on: July 14, 2015, 09:09:23 AM »
"comprehensive history, comprehensive examination, medical decision-making of moderate complexity"

"Usually presenting problems are moderate to high severity"

Yeah, this describes your situation.

You could ask for it to be re-coded. Worst they could say is no. But I wouldn't count on it.

I'm trying to get a level 3 visit for my son knocked down to a level 2, by the same reasoning; it was a re-check after antibiotics for an ear infection, doc literally looked at him, looked in his ears, and asked me if he was now doing well.

James

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Re: US - how to dispute a doctor's bill?
« Reply #3 on: July 14, 2015, 09:13:30 AM »
I think you have two options. You can dispute this at the insurance level or at the clinic level. (It wasn't the doctor that necessarily picked the code, it might have been a coder reading his chart note and determining the code to bill.)

I would start by calling the clinic you went to and cheerfully and politely dispute the charge/code you were billed for. Let them know you are happy to pay, but that the code seems unreasonable. Explain why you think that, how long the visit was and what happened, and what your understanding of the code means. Then let them explain why their code was correct and see what you can do.

Then if that wasn't satisfactory, I would call your insurance and dispute the code. Let them know you don't agree with the code that was billed for you, and why you think it was wrong. Find out what options they have to help you out, and what it might do to your charge.

I don't know what either of them will say to you, whether it will be treated professionally or not, but I think those are your two choices and there is nothing wrong or ungrateful about doing that. Health care costs so much in the states in part because nobody worries about costs, they just write the check.


Having said all that, it may very well be the correct code, but they should be able to explain why. And codes are there for a reason. A doctor might spend 90 minutes sorting out a patient and code the same code. and they pay for a lot more than just the doctor with that code, they pay for nurses, facility, marketing, missed appointments, etc, etc with that code. So I don't think the bill is that terrible for what you had checked out, but nothing wrong with finding out.

Retire-Canada

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Re: US - how to dispute a doctor's bill?
« Reply #4 on: July 14, 2015, 01:19:01 PM »
I would just decide if the difference in cost between the Level IV charge and the Level III charge is worth your time to dispute. I'm not going to play phone tag and argue for less than $100/hr.


ShoulderThingThatGoesUp

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Re: US - how to dispute a doctor's bill?
« Reply #5 on: July 14, 2015, 01:27:35 PM »
Medical billing is absolutely ridiculous, especially the opacity of it, but I'm not sure $273 is that bad. You spent ten minutes with the doctor, but how long with the nurse? Had there been a reason for the doctor to be more concerned, wouldn't you have been pissed if he had to go because he'd only scheduled you for 10 minutes?

For context, we are expecting a bill for around $700 for an emergency room visit with my daughter that turned out to be nothing to worry about. We spent about 20 minutes total with medical professionals.

AZDude

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Re: US - how to dispute a doctor's bill?
« Reply #6 on: July 14, 2015, 01:36:36 PM »
$273 seems high for a specialist visit, but it could be that high for a variety of reasons. If the doctor is out of network, for example, it could be a higher price, depending on your insurance plan. I would probably pay the $$ and then read through the plan information for your health insurance, making sure you are visiting their preferred providers in order to get the most cost-effective treatment.

Healthcare in the US is high quality, but its a nightmare to figure out billing. We had short-term insurance to fill a gap switching from my wife's employer to mine last summer, and it took weeks of haggling to come to a settlement over a check-up and vaccine for my little one. So good luck.

Reynold

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Re: US - how to dispute a doctor's bill?
« Reply #7 on: July 16, 2015, 10:03:18 AM »
I feel your pain, annajane83, my wife spends a lot of her time on things like this because of the principle. :) 

It has actually not been unusual to have a doctor's office lower a bill or a classification when challenged, so don't lose hope.  That said, part of what you were paying for here, I think, was the "new patient" premium, which is even noted in your classification code.  That exact same visit if you went to that physician regularly would probably be cheaper, maybe half the price or less, not that anyone can tell for sure given how medical stuff is billed here in the U.S. 

It is certainly a good idea to keep an eye on those kinds of things, we have changed doctors before because of bad billing practices, for example when we had an opthamologist bill both our vision plan and our health insurance for the same visit because he saw "floaters" for one of us.  When challenged, he agreed it was just a normal amount of them, nothing medically unusual, but we never got his office to fix the billing.  We eventually gave up since we didn't have to pay anything extra and the insurance company didn't seem to take any real interest in it, sigh. . . 

nienajadly

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Re: US - how to dispute a doctor's bill?
« Reply #8 on: July 16, 2015, 12:03:39 PM »
In case it helps, here's the description for a new patient level 3: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. 

Depending on what the doctor documented as reviewed, ordered, examined, etc., I would expect to see a level 3 or 4 for your type of problem/visit. 

pk_aeryn

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Re: US - how to dispute a doctor's bill?
« Reply #9 on: July 17, 2015, 03:19:15 AM »
It also doesn't seem crazy unreasonable to me, however, bills from doctor visits will be lower once you hit your deductible (if you haven't yet).  Then you might just have a co-pay or co-insurance.

This_Is_My_Username

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« Reply #10 on: July 17, 2015, 05:42:58 AM »
bill specialist

lol how is that even a job.


Quote
not that anyone can tell for sure given how medical stuff is billed here in the U.S. 

ltt

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Re: US - how to dispute a doctor's bill?
« Reply #11 on: July 17, 2015, 08:13:00 AM »
More than likely, since you are not used to the American health care system, every bill you receive will feel like a rip-off.  Wait until you go for just an office visit and see that a charge for that is around $100--of course, you would only have to pay the co-pay with your insurance.  I say pay it---the charges are not out of line for an ultrasound and, if you decide to appeal it, I have a very strong feeling that an appeal would be denied.

goatmom

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Re: US - how to dispute a doctor's bill?
« Reply #12 on: July 17, 2015, 11:00:00 AM »
$100 for an office visit?  If you find a doctor that doesn't participate with insurance (there are a few out there), I have paid between $100 and $200 for a visit.  Since the doctor doesn't have to pay the billing specialist and all the other people that jack up the prices  - he/she spends more time with me. My mechanic charges $50 an hour and I have paid $100 for a cut/color in the past.   The doctor is just doing what he/she is being told to do by billing.  Welcome to insurance driven medicine. 

FarmerPete

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Re: US - how to dispute a doctor's bill?
« Reply #13 on: July 17, 2015, 12:30:33 PM »
Since insurance companies are now forced to pay out 90% of premiums on claims, that limits their profits to 10% of premiums collected.  This gives the insurance companies a greater incentive to increase the costs of treatment, so that they can earn a larger 10% off of the larger premiums.  Insurance will never try to help you get stuff cheaper any more. 

I'm recently dealing with a stupid medical bill problem myself.  My wife got a bill for $20 for a copay because she mentioned she was having migraines during a prenatal checkup.  Prenatal checkups are free, but talk about anything other than the baby, and they'll hit you with a bill.  Then she got a bill for $125 (our deductible) after she had an ultrasound.  I wouldn't be so pissed about that, but it was like her 4th ultrasound in the last few months.  Why were the first 3 free, but this one wasn't?  Call billing, and they direct you to the dr office.  Dr office directs you to a different billing.  That billing claims they used the exact same codes, and to take it up with insurance.  Insurance hasn't a clue.  It's just so bizarre that no one can help with stuff like this.

lhamo

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Re: US - how to dispute a doctor's bill?
« Reply #14 on: July 17, 2015, 12:53:14 PM »
Annajane, just for reference sake, one of the places I called for a possible surgical follow up visit said that since I'm uninsured I would need to pay a deposit of $250 and that the bill for the initial visit would likely be between $250-500.  That is just the surgical consultation -- doesn't include cost of any tests, etc. 

The initial visit with the urgent care place (where I was seen by a physician's assistant) was $145.


James

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Re: US - how to dispute a doctor's bill?
« Reply #15 on: July 20, 2015, 10:25:30 AM »
Update- the nurse in the doctor's office rang me this morning to say not to pay the bill, as the bill specialist has agreed the level should be changed...

...Now I'm paranoid that they are changing it UP to Level V! Which I guess is a possibility - but the nurse did say this was good news so I hope that the revised bill shows a Level III charge. It will be interesting to see which way it goes, and what the final amount is.

Something I've been wondering...when I originally rang the billing department to ask how much this visit would cost (before the visit), they told me there's no way of knowing, it could be between $100 and $500 before insurance adjustment. They also told me that there is a 35% reduction for patients with no insurance.

So, my bill was $361 before adjustment, then Aetna paid $88 and it came out to $273. That amounts to a 24% reduction - i.e. it seems like I would have been better off saying I didn't have insurance? Can that possibly be right?

Really appreciating all the insight/advice so far, everyone - it makes the transition to a new system a lot easier!!!


It would be a really cruel trick to mark it up,  I just can't see them doing that. But then anything is possible...


Regarding saying you didn't have insurance, one down side is that it wouldn't count against your deductible if you pay out of pocket. So if you had a bunch more medical expenses and kept paying out of pocket you would never reach the max deductible and insurance would never pay anything.


Second, was the initial bill of $361 made through your insurance? If so that number is probably already be a reduction based on the discount your insurance carrier gets from the hospital. In other words, the bill for cash payment is almost always higher than the bill insurance companies get. (Not saying that is good or bad, just a fact)

gbbi_977

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Re: US - how to dispute a doctor's bill?
« Reply #16 on: August 10, 2015, 02:33:50 PM »
Update - bill has been revised from $273 to $122 - whoo!

Hamster

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Re: US - how to dispute a doctor's bill?
« Reply #17 on: August 11, 2015, 08:47:15 AM »
Update - bill has been revised from $273 to $122 - whoo!
I just saw this thread, and after seeing the description, there is no way this could have been a new level 4 visit. As you noted a new lvl 4 (99204) needs a comprehensive physical exam, which Wqsn't done if he just examined a breast lump. The history part might be there just off of paperwork you filled out, and medical decision making could maybe be argued based on the review of images and the potential for this to be cancerous.

If anyone cares, coding for established patients only requires meeting a certain level on 2 out of 3 components (history, physical, and medical,decision making).

The 'big thing' in outpatient medical coding is that difference between level 3 and level 4 visits. Insurers audit and dispute these, and physicians are trained to make sure there documentation supports level 4 visits for established patients.

It is really a stupid system and a waste of money and human energy - see the 'billing specialist' above.

Hamster

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Re: US - how to dispute a doctor's bill?
« Reply #18 on: August 11, 2015, 08:48:14 AM »
"comprehensive history, comprehensive examination, medical decision-making of moderate complexity"

"Usually presenting problems are moderate to high severity"

Yeah, this describes your situation.

You could ask for it to be re-coded. Worst they could say is no. But I wouldn't count on it.

I'm trying to get a level 3 visit for my son knocked down to a level 2, by the same reasoning; it was a re-check after antibiotics for an ear infection, doc literally looked at him, looked in his ears, and asked me if he was now doing well.
Curious is you had any luck. Level,3 for an established patient is a pretty low bar.

gbbi_977

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Re: US - how to dispute a doctor's bill?
« Reply #19 on: August 14, 2015, 10:01:57 AM »
Update - I got the paper bill today, and guess what? They downgraded it from Level IV to Level II! Makes me even more annoyed about the system, how easily they can say 'yep, Level IV' without being called out on it...or am I being ungrateful? Maybe they just bumped it down to Level II to appease me, as I was so friendly on the phone, but the cynic in me is having even more doubts about our health care system now.

Merrie

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Re: US - how to dispute a doctor's bill?
« Reply #20 on: August 14, 2015, 12:28:16 PM »
"comprehensive history, comprehensive examination, medical decision-making of moderate complexity"

"Usually presenting problems are moderate to high severity"

Yeah, this describes your situation.

You could ask for it to be re-coded. Worst they could say is no. But I wouldn't count on it.

I'm trying to get a level 3 visit for my son knocked down to a level 2, by the same reasoning; it was a re-check after antibiotics for an ear infection, doc literally looked at him, looked in his ears, and asked me if he was now doing well.
Curious is you had any luck. Level,3 for an established patient is a pretty low bar.

I didn't have any luck. They wouldn't change it. Apparently asking me how he's doing and peeping in his ears is indeed a level 3. If he gets another ear infection I'm going to talk about the feasibility of skipping the followup. He hasn't had one since December though.