Wednesday, February 20, 2013

Angry Patients and Office Fees

     Every now and then patients complain bitterly about how much they "got charged" for a doctor visit or a hospital stay.  Ever since the raid on my clinic, certain angry patients--egged on like the Pied Piper's followers by the government--accuse me of fraud, as though they had thought of it themselves.  
     One patient complained, recently and vociferously, on my blog, that I should not have charged her for an office visit when she stopped in to pick up her chart, even though she did not simply pick it up, but insisted on having a personal visit with me on the spot, and made a scene in the waiting room.  "Fraud!  Fraud!  Fraud!" she wrote afterward on my blog, followed by "Shame!  Shame!  Shame!"--because I had the nerve to charge her insurance for the visit.
     I remember the incident.  My receptionist had to call me out of a room, where I was attending to someone else, because this particular patient was so angry she raised the fear-level in the clinic.  The front office staff said they "couldn't take it any more," meaning they were feeling threatened by this patient's escalating temper (in the wake of the Newtown incident).  They alerted me to defuse the situation:  "Either calm the patient down or make a decision to call law enforcement," was the message.
     I was able to neutralize the situation, but it took time and required skill.  We didn't need police back-up, everyone remained safe, the patient's dignity was preserved in front of everyone in the waiting room, and I urged her to visit with me alone in an exam room.  Afterward, I returned to the patient I had abandoned on account of this emergency, but the encounter had been exhausting.
     That was an emergency office visit, whether the patient appreciated it or not.  A person who becomes violently angry in public is likely to have a personality disorder.  Our social norms are so powerful, that overriding them to give vent to internal rage in a very public place, means that an individual has lost the ability to censor primitive feelings, and therefore can appear (and become?) dangerous to others.   Perhaps the patient didn't realize it, but my intervention was an "office visit."  True, I hadn't discussed her blood pressure or headaches, but handling a personality disorder is an "office visit," too.  It required documentation in her chart, it took time, it was a "face-to-face encounter," and it was billable.
     Of the nearly 1,500 patients who "picked up" their medical records in the weeks prior to closing Colasante Clinic, only a handful required an office visit, and were billed as such.  Most patients signed a release, got answers to questions about where they might transfer their medical care, expressed sadness and gratitude, and left.  
     People who express violent anger in a public place like the doctor's waiting room often feel completely justified in doing so, in the throes of their outbursts, no matter who else might be in the vicinity or how those people might feel.  Afterward, those same angry individuals may need to ward off feelings of shame by insisting on their righteousness.  Or, shame doesn't even come close to the surface of consciousness, they are so caught up in their rage.
     The point is, office visits come in many different configurations.  But whenever a doctor has an encounter with a patient, it's likely to meet criteria for an "office visit," and is, therefore, a billable service.  An office visit is defined as a "face-to-face encounter," requiring
     Doctors don't have the luxury of deciding how much they should get paid for their services, however.  It has come to my attention that most people don't understand this.  When it comes to almost anything else you might wish to "purchase," the seller sets the price, and the customer either pays it or not.  But when doctors see patients who have insurance, the fee-for-a-product-or-service system is thrown out the window.  Almost all doctors see patients who have insurance.
     Doctors don't sent fees;  insurance companies do.  Insurance companies decide whether a doctor should be paid, how much, how often, and for what services--and they decide this after the patients have been seen and treated.  Insurance companies publish long (tens of thousands of pages, in some instances) "explanations" for what they pay and what they don't, but more often than not these explanations are obtuse, difficult to navigate, and self-contradictory.  Moreover, they don't follow standard guidelines for good medical care, leaving doctors to tell patients they should get a treatment that "isn't covered."  It's a rare patient who will pay for a service out-of-pocket when it isn't covered by an insurance plan.  Instead, the patient is likely to insist that a doctor call the insurance company and petition, plead, or file a request for an "override" for the service.  A great deal of time in a doctor's office is spent behind the scenes advocating for patients in this way, often to no avail.
  Nevertheless, if a doctor agrees to "take assignment" with an insurance company, he or she has to comply with the insurance company's rules and guidelines, even if they are not in a patient's best interests.  There is almost no room for negotiation.  This is something that aggravates doctors more than anything, and accounts for the fact that many doctors want to leave medicine, or at least stop signing contracts with insurance companies.
   Insurance companies have interpolated themselves between the doctor and the patient.  They decide what a patient "needs," not doctors--even though insurance companies aren't doctors, don't know the patients, and aren't equipped to practice medicine.  They're practicing it, anyway--and very badly, because their primary concern is profits, not people.  Hence, for decades Blue Cross refused to cover a screening colonoscopy in patients over age fifty, despite every medical guideline supporting the need for this preventive test.  Medicaid doesn't cover flu shots.  Medicare doesn't cover dietary counseling for diabetes.  Choices won't cover a range of birth control options.  Most insurances won't cover the shingles vaccine.  Medicare doesn't pay for the pertussis vaccine.  The list goes on and on, and physicians are left to guess about which guidelines for good medical care will be covered by a particular insurance carrier, and which won't.  If I give a pertussis vaccine or insert an IUD for a patient, because a representative at a patient's insurance company said the service would be covered, but then it's denied, I have to consider it a loss for my clinic.  Fighting with insurance companies over nonpayments costs more than absorbing the loss.  It's one of the ways insurance companies maximize profits:  don't pay for services, and make it very difficult for physicians to figure out why standard services aren't covered.  A long telephone wait time, and a barricade of poorly-informed telephone clerks at the front lines of insurance companies guarantee that doctors' offices will give up the fight for payment, especially since every insurance carrier plays the same game.  
     Doctors must send insurance companies a "charge," when they send a claim (claim=invoice for services) but the charge is irrelevant, having no bearing on payment.  When patients get EOB's ("explanation of benefits," a fancy name for how much was paid to the doctor and for what) they see a column for "charge," and think the doctor is actually "charging" a fee for a service.  In fact, it makes no difference what number the doctor puts in the column for "charge."  It's necessary for the claim to be processed, but it isn't used by the insurance.  (My "charges" were all set at twice the "Medicare allowable," and this is how many doctors create a number for the "charge" column on a claim form.
     Doctors also list the diagnoses and services provided to patient (in alphanumeric language).  These are listed on the EOB too, but are translated back into English in language that makes it difficult for patients to know what service was supposed to have been provided.  Sometimes the language is not even recognizable as a service, which raises a red flag for patients who then may suspect doctors of fraud.
     EOB's have columns for DOS (date of service), Service, Diagnosis (sometimes), Charge, Allowable, Deductible, Payment to Provider, and Copay.
     The "Allowable" is the fee the insurance company has set for the service provided.  Every fee has an "allowable."  This is what the insurance company has decided it will pay.  If the doctor happens to "charge" less than that amount, the insurance company will pay less.  But if the doctor charges more, the insurance company has put a ceiling on the payment, and won't pay more than the allowable.
     In general, insurance companies only pay a portion of the allowable, leaving the rest for the patient to pay as a copay or deductible.
     Far too often, an insurance company decides to pay nothing--at least not until the doctor gives more information or copies records.  This is a standard stalling technique used by insurance companies all the time, and it pays off.  Sixty percent of nonpayments by insurance companies in Florida are never contested by the doctor's office--usually because the doctor doesn't even know the claim wasn't paid, and the billing employees ignore the extra work required to collect a claim.  Then, the patient saw the doctor for free.  Most of the time, even patients don't know this is happening.
     If you want to know how much your doctor is "charging" for your office visits or other services, you must refer to the "Allowable" line on the EOB you receive, and then look at the amount actually paid.  Doctors who accept insurance know they have to accept the insurance company's fee schedule.  So their "charge" is, in fact, the allowable.
     You might be surprised to find out how often the payments to your doctor for taking care of you are zero.  By working without pay, in this way, doctors have become unintentional givers of charity, as they have been for thousands of years.  But these days, the charity is forced on them by insurance companies, who claim all the nonpayments to doctors as profits.  In this way, insurance companies have outwitted--or defrauded--us all.


  1. While I am not at liberty to discuss any particular patient's case, I will reiterate that when a patient has a face-to-face encounter with a physician in the confines of the physician's office, in general this constitutes an office visit, which is a billable service. The office visit charge is a compilation of the work performed for that patient, including phone calls and anger-management, interventions sometimes performed by ancillary staff, like nurses, whether the patient considers the anger "legitimate" or not. Again, I am sorry you had a bad experience. I can only reiterate that, of the 1,500 or so patients who picked up their records, only a handful of them needed a face-to-face visit with me or another provider,and only two were angry and upset about the way their records-requests had been handled. (I consider the transition to other medical providership, therefore, smooth, and a consequence of my staff's hard work and people-skills.) Face-to-face visits with a provider are always documented and billed--unless they are purely social, which is rare.