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Doctor's Double-Billing Illustrates Broken System

Philip Betbeze, for HealthLeaders Media, April 12, 2013

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.

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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.