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Doctor's Double-Billing Illustrates Broken System

Philip Betbeze, for HealthLeaders Media, April 12, 2013

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.

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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.