Doctor bill question

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soccerdad12
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Doctor bill question

Post by soccerdad12 » Wed Apr 26, 2017 8:42 am

I had a small puncture wound in my foot and went into my primary care practice. I couldn't see my normal doc, but saw an NP. Visit lasted about 5 minutes and she just looked at it and didn't do anything. No big deal since it healed on it's own like she said it would. NP was totally fine and I was happy.

Today I get the bill for the $125 (after the insurance adjustment) and it says I saw an MD (which I didn't). Wouldn't the bill be less if I saw a NP and not a MD?

I am not going to dispute it, but wondering if this is just how billing works or if the medical office is trying to get a higher bill saying I saw a doc instead of the NP?

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dm200
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Re: Doctor bill question

Post by dm200 » Wed Apr 26, 2017 8:57 am

soccerdad12 wrote:I had a small puncture wound in my foot and went into my primary care practice. I couldn't see my normal doc, but saw an NP. Visit lasted about 5 minutes and she just looked at it and didn't do anything. No big deal since it healed on it's own like she said it would. NP was totally fine and I was happy.
Today I get the bill for the $125 (after the insurance adjustment) and it says I saw an MD (which I didn't). Wouldn't the bill be less if I saw a NP and not a MD?
I am not going to dispute it, but wondering if this is just how billing works or if the medical office is trying to get a higher bill saying I saw a doc instead of the NP?
With previous Physicians and insurance, we would often see a NP for some matters (like this). I might contact the insurance company and ask about the billing code and whether it makes any difference whether you saw a Physician or the NP.

My recollection is that the "office visit" charge was the same whether we saw a NP or the Physician (MD).

RudyS
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Re: Doctor bill question

Post by RudyS » Wed Apr 26, 2017 9:02 am

Our bills always show the MD's name even when we saw the NP. This seems to be normal.
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High Income Parent
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Re: Doctor bill question

Post by High Income Parent » Wed Apr 26, 2017 9:07 am

Usually an MD supervises the NP and reviews the assessment and plan. That is what the MD charge is for.
You can call the insurance company and see if there is a difference in charge of an MD didn't touch you but I would be surprised if there is any difference.
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Re: Doctor bill question

Post by Rupert » Wed Apr 26, 2017 9:17 am

This has happened to me. Under my insurance, my co-pay is lower if I see an NP, rather than the MD. So it's worth disputing for that reason. But I let the insurance company handle everything else, i.e., if the insurance company wants to pay the MD rate when I see an NP, alright by me, but I'm not paying the MD co-pay.

soccerdad12
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Re: Doctor bill question

Post by soccerdad12 » Wed Apr 26, 2017 9:32 am

I am on a HDHP, so the cost impact is greater to me than a co-pay.

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dm200
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Re: Doctor bill question

Post by dm200 » Wed Apr 26, 2017 9:36 am

Rupert wrote:This has happened to me. Under my insurance, my co-pay is lower if I see an NP, rather than the MD. So it's worth disputing for that reason. But I let the insurance company handle everything else, i.e., if the insurance company wants to pay the MD rate when I see an NP, alright by me, but I'm not paying the MD co-pay.
Since this may be both insurance and details dependent, I would make an inquiry to the insurance company before actually "disputing" the bill.

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Re: Doctor bill question

Post by prudent » Wed Apr 26, 2017 9:56 am

Topic moved to Personal Consumer Issues.

Kazeflame
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Re: Doctor bill question

Post by Kazeflame » Wed Apr 26, 2017 6:00 pm

Doctors can have NPs work for them and supervise just by listening to and agreeing with the story. The bill for the visit is based more on complexity than who saw the patient. It may not be any different unless you have separate copays for MD vs NP.

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Re: Doctor bill question

Post by dm200 » Wed Apr 26, 2017 6:07 pm

Kazeflame wrote:Doctors can have NPs work for them and supervise just by listening to and agreeing with the story. The bill for the visit is based more on complexity than who saw the patient. It may not be any different unless you have separate copays for MD vs NP.
No expert on the all-important "billing codes", but are the codes the same whether the patient is seen (in person) by a NP vs Physician (MD or DO)? I am under the impression the codes are the same.

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Re: Doctor bill question

Post by Kazeflame » Wed Apr 26, 2017 6:14 pm

dm200 wrote:
Kazeflame wrote:Doctors can have NPs work for them and supervise just by listening to and agreeing with the story. The bill for the visit is based more on complexity than who saw the patient. It may not be any different unless you have separate copays for MD vs NP.
No expert on the all-important "billing codes", but are the codes the same whether the patient is seen (in person) by a NP vs Physician (MD or DO)? I am under the impression the codes are the same.

That's right, the codes are the same.

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Re: Doctor bill question

Post by kmurp » Wed Apr 26, 2017 6:17 pm

Don't know for primary care but for my area the billing codes differ if it's just a nurse, a nurse directed by a doc or just a doc alone. That said , payment is exactly the same in all three situations.

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Re: Doctor bill question

Post by Pajamas » Wed Apr 26, 2017 6:17 pm

Kazeflame wrote:Doctors can have NPs work for them and supervise just by listening to and agreeing with the story.
It depends on the state. Some states authorize fully independent practice for Nurse Practitioners while other states have various restrictions of practice vs. MDs. Required "supervision" often consists of having an MD available for consultation on an as-needed basis and the MD does not need to be physically present. Only a minority of states require any form of direct "supervision."

https://www.aanp.org/legislation-regula ... nvironment

NPs use the same billing codes as MDs and if the charges are different, it is based strictly on the contract with the patient's health coverage provider.

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Re: Doctor bill question

Post by dm200 » Wed Apr 26, 2017 6:29 pm

The degree to which a primary care health practice uses Nurse Practioners is, I believe, a factor in choosing a Primary Care practice. Use of NPs can be either positive or negative, depending on the specifics of the NP and the attitude of the patient.

With previous primary care physicians, I never felt shortchanged if I saw a NP for a particular situation or for the majority of my annual health exam.

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Re: Doctor bill question

Post by Pajamas » Wed Apr 26, 2017 6:35 pm

dm200 wrote:The degree to which a primary care health practice uses Nurse Practioners is, I believe, a factor in choosing a Primary Care practice. Use of NPs can be either positive or negative, depending on the specifics of the NP and the attitude of the patient.

With previous primary care physicians, I never felt shortchanged if I saw a NP for a particular situation or for the majority of my annual health exam.
Most scientific studies demonstrate that patients are more satisfied with the care provided by Nurse Practioners and also that NPs achieve better patient outcomes. NPs provide mostly primary care and tend to spend more time with their patients. There may be even more basic reasons for the differences. NPs tend to be female and female MDs also tend to outperform male MDs.

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Re: Doctor bill question

Post by oru.rd » Wed Apr 26, 2017 7:34 pm

Pajamas wrote: Most scientific studies demonstrate that patients are more satisfied with the care provided by Nurse Practioners and also that NPs achieve better patient outcomes. NPs provide mostly primary care and tend to spend more time with their patients. There may be even more basic reasons for the differences. NPs tend to be female and female MDs also tend to outperform male MDs.
I don't think any of the major journals (NEJM, Lancet, etc.) have reported that NPs achieve better outcomes. As with anything else in healthcare, it is a team effort. While some patients may be more satisfied with the care provided by NPs, in most practices there is certainly a selection bias where patients with complex conditions (or temperment) are routed towards a physician. Also, there is some research showing that female MDs may outperform male MDs, just like some research has shown that eggs are good for you and some research has shown that eggs are bad for you. Also, no research to date shows that female NPs outperform male MDs. Again, is a team effort.

OP, I'd also recommend speaking with your insurance first and getting a better explanation of what the bill was. If still in doubt, you can request a copy of your medial records from the medical encounter and speak with the practice manager.

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Re: Doctor bill question

Post by Kazeflame » Wed Apr 26, 2017 8:15 pm

oru.rd wrote:
Pajamas wrote: Most scientific studies demonstrate that patients are more satisfied with the care provided by Nurse Practioners and also that NPs achieve better patient outcomes. NPs provide mostly primary care and tend to spend more time with their patients. There may be even more basic reasons for the differences. NPs tend to be female and female MDs also tend to outperform male MDs.
I don't think any of the major journals (NEJM, Lancet, etc.) have reported that NPs achieve better outcomes. As with anything else in healthcare, it is a team effort. While some patients may be more satisfied with the care provided by NPs, in most practices there is certainly a selection bias where patients with complex conditions (or temperment) are routed towards a physician. Also, there is some research showing that female MDs may outperform male MDs, just like some research has shown that eggs are good for you and some research has shown that eggs are bad for you. Also, no research to date shows that female NPs outperform male MDs. Again, is a team effort.

OP, I'd also recommend speaking with your insurance first and getting a better explanation of what the bill was. If still in doubt, you can request a copy of your medial records from the medical encounter and speak with the practice manager.


+1

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Pajamas
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Re: Doctor bill question

Post by Pajamas » Wed Apr 26, 2017 8:48 pm

oru.rd wrote: I don't think any of the major journals (NEJM, Lancet, etc.) have reported that NPs achieve better outcomes.
No, and it is highly unlikely that any major medical journals will accept research for publication in the near future that demonstrates it, because physicians have fought tooth and nail against the growth of non-physician primary care practitioners. However, they have not been able to provide real evidence that any of their arguments are valid and have had to ignore a lot of solid evidence that they are not valid.

At this point, about 75% of primary care providers are MDs or DOs and about 25% are either NPs or PAs, and the growth is definitely on the non-physician side.

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Re: Doctor bill question

Post by ram » Wed Apr 26, 2017 8:58 pm

In most states NP's require physician supervision. The extent of the supervision is variable in different states. It is reasonable to assume that you got the benefit of a MD's knowledge even though you did not meet face to face with him. At the very least it was available if required.
Whether the charge is lesser for you is dependent on the contract between you and your health insurance. Whether the charge is less for the NP is dependent on the contract between the medical practice and the health insurance company.
Ram

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Re: Doctor bill question

Post by oru.rd » Wed Apr 26, 2017 9:20 pm

Pajamas wrote:
oru.rd wrote: I don't think any of the major journals (NEJM, Lancet, etc.) have reported that NPs achieve better outcomes.
No, and it is highly unlikely that any major medical journals will accept research for publication in the near future that demonstrates it, because physicians have fought tooth and nail against the growth of non-physician primary care practitioners. However, they have not been able to provide real evidence that any of their arguments are valid and have had to ignore a lot of solid evidence that they are not valid.

At this point, about 75% of primary care providers are MDs or DOs and about 25% are either NPs or PAs, and the growth is definitely on the non-physician side.
Not sure how this tangent based on opinions helps the OP in a finance forum. There are over 25,000 scientific journals out there. Major breakthroughs are typically published in the top tier journals and their editorial boards are not entirely physicians (PhDs are also included). If NPs alone did infact provide superior outcomes over physicians as you claim then these findings would have made their way into a top tier journal. If, as you suggest, physicians fought tooth and nail to keep it from select medical journals, then it's safe to assume that these findings would be in one of the many hospital administration journals (not included in the 25,000 count) where few physicians would be on the editorial board. Reality is that there is a cap on the number of physicians that can be trained (and has been since the 1990s). The physician shortage has been helped considerably by the rising numbers of PAs and NPs. Medicine has evolved considerably to become team oriented and patient-centered. Savvy physicians embrace working with NPs and PAs.

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Re: Doctor bill question

Post by dm200 » Thu Apr 27, 2017 7:22 am

Pajamas wrote:
dm200 wrote:The degree to which a primary care health practice uses Nurse Practioners is, I believe, a factor in choosing a Primary Care practice. Use of NPs can be either positive or negative, depending on the specifics of the NP and the attitude of the patient.
With previous primary care physicians, I never felt shortchanged if I saw a NP for a particular situation or for the majority of my annual health exam.
Most scientific studies demonstrate that patients are more satisfied with the care provided by Nurse Practioners and also that NPs achieve better patient outcomes. NPs provide mostly primary care and tend to spend more time with their patients. There may be even more basic reasons for the differences. NPs tend to be female and female MDs also tend to outperform male MDs.
While there is generally increasing use of NPs and PAs in Primary Care, when my wife and I returned to Kaiser sx years ago, Kaiser had eliminated nurses and nurse practioners from adult primary care and hired more Physicians (MD and DO, Internal medicine and Family practice). I have found that very interesting.

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Re: Doctor bill question

Post by Broken Man 1999 » Thu Apr 27, 2017 7:56 am

dm200 wrote:The degree to which a primary care health practice uses Nurse Practioners is, I believe, a factor in choosing a Primary Care practice. Use of NPs can be either positive or negative, depending on the specifics of the NP and the attitude of the patient.

With previous primary care physicians, I never felt shortchanged if I saw a NP for a particular situation or for the majority of my annual health exam.
One of my specialists has NPs, and I haven't noticed a bit of difference. The issue of quality of care isn't something that stresses me as I figure anyone hired by a doctor who enjoys a thriving practice is going to be vetted pretty heavily. No matter who you see, any finger of blame would most likely be pointing back at the doctor in charge.

My co-pay is $5 for PCP, $20 for specialist no matter who I see. And it appears there is no difference in the payment from the insurance company.

I will say although I have no issues with NPs, I prefer older, grizzled doctors for specialists. I figure I'm less apt to show up with something they have never seen.

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Re: Doctor bill question

Post by dm200 » Thu Apr 27, 2017 8:24 am

Broken Man 1999 wrote:
dm200 wrote:The degree to which a primary care health practice uses Nurse Practioners is, I believe, a factor in choosing a Primary Care practice. Use of NPs can be either positive or negative, depending on the specifics of the NP and the attitude of the patient.
With previous primary care physicians, I never felt shortchanged if I saw a NP for a particular situation or for the majority of my annual health exam.
One of my specialists has NPs, and I haven't noticed a bit of difference. The issue of quality of care isn't something that stresses me as I figure anyone hired by a doctor who enjoys a thriving practice is going to be vetted pretty heavily. No matter who you see, any finger of blame would most likely be pointing back at the doctor in charge.
My co-pay is $5 for PCP, $20 for specialist no matter who I see. And it appears there is no difference in the payment from the insurance company.
I will say although I have no issues with NPs, I prefer older, grizzled doctors for specialists. I figure I'm less apt to show up with something they have never seen.
Broken Man 1999
I occasionally deal with NPs for certain aspects of specialty care. It was a NP, for example, that conducted a treadmill stress test on me a few years ago. I never had this, but I know specially trained NPs often do flex sig exams.

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Re: Doctor bill question

Post by Pajamas » Thu Apr 27, 2017 10:44 am

oru.rd wrote:Savvy physicians embrace working with NPs and PAs.
True, but there are many unsavvy physicians.

For instance, the AMA insists in their official public statements that NPs should not practice independently but only as part of a team led by physicians.

https://www.ama-assn.org/ama-statement- ... ice-nurses

However, the AMA doesn't offer any scientific evidence to support their position, only vague statements that such a model can be successful, which is, of course, true, but it does not mean that it is the best model.

They conveniently ignore the overwhelming scientific evidence that non-physician practitioners can and do provide excellent quality basic care without supervision. They should also present evidence that physicians are the best choice to lead a health care team.

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Re: Doctor bill question

Post by oru.rd » Thu Apr 27, 2017 8:29 pm

Pajamas wrote:
oru.rd wrote:Savvy physicians embrace working with NPs and PAs.
For instance, the AMA insists in their official public statements that NPs should not practice independently but only as part of a team led by physicians.

https://www.ama-assn.org/ama-statement- ... ice-nurses

However, the AMA doesn't offer any scientific evidence to support their position, only vague statements that such a model can be successful, which is, of course, true, but it does not mean that it is the best model.

As above, that's because quality scientific evidence doesn't exist to support one side of the argument or the other. Key words are quality evidence.

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Re: Doctor bill question

Post by AirTimeMD » Thu Apr 27, 2017 10:32 pm

You should have been charged a 99xxx code.

99201-99204 as a new patient
99211 - 99214 as an established patient

As many have said in this thread, the MD may bill as supervising thru the NP. The MD needs to sign-off on the treatment plan. There is also something called "incident-to" billing, where the MD needs to evaluate the patient and set the treatment plan and then the mid-level provider can follow thru the treatment plan.

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Re: Doctor bill question

Post by Mtn7880 » Thu Apr 27, 2017 11:11 pm

To Pajamas: I suspect that you're a nurse practitioner disgruntled with your MD counterparts. I'm not sure how the argument that a nurse practitioner that gets a nursing degree followed by an ONLINE NP degree (while working full time as a nurse) trumps an MD education. I think it's hard to argue that less education is better for patient outcomes. The sad reality is that you don't know what you don't know, and it's the patients that suffer the consequences of missed or delayed diagnosis. There's a reason that physicians train in a residency where 80 hour work weeks are standard (there's just that much to learn if you want to be competent) and oversight is there for WHEN mistakes are made. Advocating for independent nurse practitioner practice bypasses this safety net and patients suffer because of it

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Re: Doctor bill question

Post by White Coat Investor » Thu Apr 27, 2017 11:30 pm

I directly supervise NPs and PAs and have for my entire career in multiple facilities and practice scenarios.

If you couldn't bill as much or nearly as much for a NP/PA seeing the patient as the doctor, there would be no jobs for NP/PAs. The point of these advance practice clinicians, at least in areas where there is no shortage of medical providers such as any reasonably large city in the US at least as far as patients with regular medical insurance, is to pay an APC less than you would have to pay a doc and keep the difference. The patient and their insurance pay the same but the care is rendered by someone that costs less. If we couldn't collect way more than the NP/PA cost us, they would be out the door as fast as their contract allowed.

Only a fool would argue the care is better or even equal. But many times it is "good enough" and a lot more profitable. Is it safe? I would argue it is as long as the supervision is tight. Tight supervision means different things in different specialties, but in my case, it means the PA is sitting at the computer next to me for 8 hours a day, the PA is only seeing the lower acuity patients, and anything that is at all beyond very routine cases is discussed with me in real time as the care happens.

I mean, come on. Take your top-notch undergraduate students and send them to 4 more years of school and 3-7 years of post-graduate training. Or take the students who weren't quite top-notch and send them to one more year of school, one year of post-graduate training, and hope they learn enough on the job to eventually do okay in a supervised practice.

Lest you think I'm making that up, here are the statistics on matriculants to both types of schools:
https://www.thepalife.com/who-gets-in/
https://www.aamc.org/download/321494/da ... blea16.pdf

and that ignores the fact that the PA/NPs are by and large taking different (less academically rigorous) science classes than those applying to med school.

"But there's no evidence doctors are better. We need a randomized controlled trial!" they say.

There is also no study that shows parachutes work. However, some things are so obvious to anyone paying attention that they don't need to be studied. This, like parachutes, is one of those.
http://www.bmj.com/content/327/7429/1459

Is every doctor good and every PA/NP bad? Of course not. Can everyone think of an NP they'd rather see than some doctor they know? Of course. But by and large, the average doctor is going to know more, be more skilled at procedures, be better at problem solving, practice more independently of other specialists etc when compared to the average PA/NP. And the brand new PA/NP? Watch out!
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Re: Doctor bill question

Post by oru.rd » Fri Apr 28, 2017 7:07 pm

Mtn7880 wrote:To Pajamas: I suspect that you're a nurse practitioner disgruntled with your MD counterparts. I'm not sure how the argument that a nurse practitioner that gets a nursing degree followed by an ONLINE NP degree (while working full time as a nurse) trumps an MD education. I think it's hard to argue that less education is better for patient outcomes. The sad reality is that you don't know what you don't know, and it's the patients that suffer the consequences of missed or delayed diagnosis. There's a reason that physicians train in a residency where 80 hour work weeks are standard (there's just that much to learn if you want to be competent) and oversight is there for WHEN mistakes are made. Advocating for independent nurse practitioner practice bypasses this safety net and patients suffer because of it
I couldn't agree more

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Re: Doctor bill question

Post by toofache32 » Fri Apr 28, 2017 10:35 pm

I firmly believe NPs cause a dramatic increase in costs to the healthcare landscape. They order tests and tests and more tests that are not always necessary. I see patients referred to me from NPs and patients always wonder why I don't need to see all those test results to come to the same conclusion.

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