“How much are you charging me for this, doc?” is a question patients sometimes ask. The only honest answer today is “I don’t know.”
If insurance is involved, the process is anything but telling patients a number and having them dump the dough on the counter. I’ll attempt to elucidate the murky, mysterious evolution of your medical bill. Doctors (providers, but I’m a doctor, so that’s the term I use) are pretty much pawns in the game of medical business. This will be mostly about office visits.
So, you come in, and I, old Doc B, ask how you are. You say fine. (So what are you doing there? No, wait, sorry.) You go through the medical discussion, the reason for the visit and bid me adieu. I then dictate the note, which is occasionally illegible, and check a box for a diagnosis code, the key to the entire “system.”
Then I decide how much time we spent doing diagnosis, or counseling, or cutting you up, or other fun activities. After “training in coding” I learn I am supposed to crank up the separate charge code as high as is permitted legally. I was never well house-broken.
Next, dictation and charge go to the “coder,” the medical business side’s linchpin. Usually a non-medical person, with training on the job or at a tech college, reads your note, matches it with the “rules” to see if you charged too much — or not enough (my style). Without consulting me, the coder often simply changes the charge.
I have stories back from patients. Like one where a young fellow I knew since he was a kid had a small facial blood vessel burned off, code 17000, about $100 (way too high already). The coder changed it on her own to 17006 for about $1,000. His insurance didn’t question it, and paid a large chunk of it. I could do nothing.
After the coder sends the bill on, the insurance company receives it. Most of the time the contracts between clinics, hospitals, etc., agree to “accept assignment.” This means the insurance company decides what the service is worth, compared to what was charged by the clinic, and it is almost always less, by a lot. They then pay a pre-agreed percentage of that number, the charge they assign the service, based on the contract they have with you or your employer.
The next factor in this gruesome game is your deductible.
Do you have to pay $100 out of pocket or $10,000 before your insurance company will pay anything? Or, if you have paid that much, then what percent of the reduced charge will they pay? Eighty percent and you twenty?
This mutated and permuted price is then returned to the hospital or office. In turn, it is sent to you, probably after enough time that you forgot you ever went to old Doc B. You have likely received bills in between, stamped with “submitted to insurance.” When you come to after reading the final dollar figure, you have to decide whether you’re going to get another paper route, auction off one young child, or whatever, to pay it.
The other aspect is whether you can ever decode how that final amount was calculated through this tortuous morass of steps.
Should the price the insurance paid be contested, the bill is plunged back into the catacombs of insurance computers and formulas, until it is frequently denied. It may be resubmitted and re-denied until they wear you down so you capitulate and pay.
When I enter a charge code, I have not the slightest idea of the price. If I do something in the visit and dictate I did, I have to charge. It is no longer allowed to “no charge” at many corporate medicine clinics. If I do it and don’t say I did it in the note, it’s technically illegal. At one clinic I know, the dollar amounts of the charges have been deleted.
The Minneapolis Star Tribune had a story about a patient whose primary provider noticed she had a wart on her thumb during the exam and asked whether she could treat it. She put some acid and a Band-Aid on it. Five minutes. The code was minor surgery for $352. Both medical adversaries, clinic and insurance, said she had to pay it. She thought it was free. She has a high deductible.
These tales of woe are woven into the fabric of medical business, which seems to have eclipsed medical practice, except in a few places. A few doctors are going on their own, and taking cash only. The “clinics” in drugstores do mostly that. At least you know it’s a set price for the ear exam, and you won’t wind up paying whatever four months later.