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Doctor's Double-Billing Illustrates Broken System

Philip Betbeze, for HealthLeaders Media, April 12, 2013

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.

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23 comments on "Doctor's Double-Billing Illustrates Broken System"


Holly DeMuro (4/19/2013 at 11:36 PM)
Performing a sick and a well visit on the same service date is a completely legitimate billing practice http://bit.ly/ZDg4ow

ptrower (4/18/2013 at 5:40 PM)
I had a similar incident when I was traveling out of town and my son developed pink-eye. I went to an urgent care center run by a local hospital that was located in a separate building from the hospital and was clearly labeled as urgent care. After a lengthy wait, my son had his three minutes with the doctor, got his prescription, we paid our copay and left. A few days later, I received a bill from the hospital system for the balance due after the insurance paid. When I examined the bill, I found that I had been billed for the visit as an emergency suing the emergency service UB codes. The insurance refused to pay and I was being billed for the difference of about $450. I called the hospital business office and was told that they had all kinds of complaints about billing for the urgent care center but that the bill was accurate. I called the hospital's compliance department and had several lengthy discussions with them. I ran the coding by the Director of Chargemaster for the health system I work for and as I suspected there was no justification for how it was coded and billed. I was eventually able to convince my insurance to pay it as a doctor's visit but there was still $250 left that I finally paid in order to avoid going to collection.

Howard S. Siegel, MD (4/18/2013 at 2:17 PM)
The use of the -25 modifier (a separately identifiable condition) is nothing new to billing and coding and has resulted in changes to the description of the modifier in the past. Blatant abuse of this coding/billing practice has and will continue to occur so long as the system allows for it. What is more troubling for me is 1) Apparent inappropriate use of Antibiotic in an asymptomatic 2 year old, and, 2)the gall of the Pediatrician to actually bill for it. As a Pediatrician, I have seen multiple concerns during routine physical exams, none of which needed to be treated and none of which were billed for. That is the Art of Medicine and not the Business of Medicine. There will always be those physicians that maximize profit over relationships.