Generally, I try to keep my personal life out of these columns. Most of you don't know me, after all, and I figure you're probably much more interested in my views on healthcare leadership strategies than in the details of my personal life.
But infrequently, the two dovetail, and my experience last week with my insurance policy and my son's pediatrician's billing policies perfectly highlights the difficult work that is in store for those of us who would like to see more value in healthcare.
Having just turned two, my son was due for a well check. Well checks, thanks to my health insurance policy, represent the only healthcare my family receives at no out-of-pocket cost. He gets his shots if needed, and is weighed, measured, poked, and prodded. So my wife took him in.
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During the course of the examination, which includes checking the ears, of course, the doctor found a previously unknown ear infection and prescribed an antibiotic. My wife thanked the doctor and was soon on her way to the drugstore and home.
A couple of weeks later is the point at which I feel like we entered the Twilight Zone. That's when we got a bill for an "office visit" on the day my son had his well visit. Note that we only had one visit; this will be important later.
Because we are required to meet a high deductible before our insurance starts paying for sick care, payment for this second office visit comes out of our own pocket. Separately, presumably, the insurer also got a bill for an "office visit" since the well care checkup, as I mentioned, is covered.
Wanting to know more about how it's justified to bill two office visits for the price of one, I called my insurance company. The following is the maddening discussion that ensued with a person I'll call Michael (not his real name), and it's pretty much verbatim:
Me: Why, when my child goes for a well visit, and the physician finds an ear infection, do I have to pay for another office visit?
Michael: Yes, they are allowed to do that, as bad as it may be. The way it works, as long as it's a routine service, you would not incur fees. If you go thinking it's a wellness visit and they find something, the way they send the coding over, the coding for the ear infection processes differently—as another office visit.
Another way to look at it, too, is for a wellness visit, the second anything is abnormal, that would properly take the different benefit. I'll put a note about this conversation, but just to really make sense about this, I wish the doctors would do it differently, and maybe schedule a second visit.
Me: But Michael, that doesn't solve the problem. Scheduling a second visit to treat something you already found during the first free one when the only treatment is a prescription? That would mean even more ridiculous bureaucratic nonsense—the equivalent of scheduling another visit just to fill in the blanks on some form. My point is: This is double billing. I mean, you guys are the insurers; you negotiate these things with the docs, why do you allow this?
Michael: Well, it's negotiated, but this is something we haven't been able to get them to do. A lot of other patients complain about it, and this is a conversation you need to have directly with your doctor.
Me: Well, we have had that conversation, and they gave me the same runaround that you're giving me. This is not your fault, but this is a big reason why my employer and I use you to interact with the provider. You have negotiating power. Alone, we don't. In fact, they tell us they have to bill twice for this kind of visit. They told my wife it's a federal law, but I've yet to find any law that governs this, and I cover healthcare for a living.
Michael: Well, they don't have to. They don't have to do anything, but when they process the ear infection, it's a different code, and they know it generates another bill.
Me: Well, it doesn't sound like I have the power to do anything about it other than get a new doctor.
Michael: I see where you're coming from, but they would probably all try to do it this way.
Me: Well, at my level, and at the level of me paying for my own care up to $1,000 per child or adult, it's wrong. I mean, she has to look in his ears as part of the well visit. Just because she found an ear infection that she writes a prescription for shouldn't give her the ability to effectively double-charge us for an office visit. I would be OK with paying for one of the two, but this kind of thing is why healthcare takes up 20% of the national budget.
Michael: I agree with you and I sympathize, but according to the contract, this is the way it works. I am going to put a note on your account that we talked with you about it.
Me: Thanks, I guess.
Michael: We might be able to have conversations about this with the doctor's office.
Me: I understand healthcare is a mess, but in the past we never saw it. That was before people with insurance were paying for their own healthcare out of pocket. But y'all need to do a better job of negotiating stuff like this where the doc does no more work, but gets paid twice.
Michael: I'll put a note on your account about this sir.
Me: Thanks for your help.
So, that's where we left it, and that's where it will probably continue to be left. I like to think I am relatively sophisticated at navigating the healthcare system, but I'm at a loss on how to navigate this.
If this is what we can all expect to encounter when trying to resolve a simple primary care visit (or visits, depending on your point of view, apparently), it's tough to see how the individual consumer can ever be expected to alter practices like this. The only choice I have is to find a new doctor, and as the insurance company representative noted, all doctors do this.
What no one seems equipped to do is answer the question of why.
Philip Betbeze is the senior leadership editor at HealthLeaders.