Is General Practitioner [billing Medicare correctly?]

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Paulie
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Is General Practitioner [billing Medicare correctly?]

Post by Paulie » Tue Feb 05, 2019 1:40 pm

I went in for my yearly MEDICARE WELLNESS exam.
According to the book there are no other charges or co payments for a yearly Medicare Wellness, unless one goes in with other complaints.

I made the apmnt for Wellness only.

I received an invoice with 3 lines.
One for the Wellness
One for Advanced Life Planning
One for an acid reflux problem I have had for years and attended to by a GI guy I visit not this GP.

I asked about the charges and was told that he talked about these topics with me and they coded them that way.

I told the billing person I have no control over things he wants to bring up and if he chooses to bring them ups its not my problem and does not give them the right to bill me medicare and or BSBC.

They charged me a Copay for the reflux Consultation and the Advanced Life Planning BS.
The medicare book says Life Planning is part of a wellness visit.

Does it sound like fraud to you guys, does to me and a way to bill medicare and me.

Any thoughts

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bengal22
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Re: Is General Practitioner Scamming Medicare

Post by bengal22 » Tue Feb 05, 2019 1:47 pm

I would not call it fraud but definitely the doctor is trying to inflate charges.
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southerndoc
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Re: Is General Practitioner Scamming Medicare

Post by southerndoc » Tue Feb 05, 2019 1:54 pm

There are certain requirements for office visits. Advanced planning may be one of them. Even though you are followed by a GI for your GERD, the PCP should be your primary physician and should discuss everything that you see a consultant/specialist for.

Fraud is when you're billed for an EKG that wasn't performed. Doesn't sound like it's fraud what your PCP did. Sounds like he/she is being thorough.

Rupert
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Re: Is General Practitioner Scamming Medicare

Post by Rupert » Tue Feb 05, 2019 1:56 pm

That's not fraud.

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Re: Is General Practitioner Scamming Medicare

Post by Shallowpockets » Tue Feb 05, 2019 2:04 pm

It is real hard to stay within the parameters for this medicare exam. When could you not answer some questions that may run off the page? Most of us do not know how this works, but how it should work is for the MD to ask only yes/no questions without any elaboration. Nothing beyond that. Then take your blood pressure, no discussion there, and send you out the door.

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Re: Is General Practitioner Scamming Medicare

Post by Nowizard » Tue Feb 05, 2019 2:08 pm

There are often billing issues when the physician uses his standard protocol for an annual exam instead of the Medicare one. For example, an EKG would not be covered and a variety of lab tests would also be extra. If you plan to have your PCP monitory your GERD, then the charge is appropriate but it the PCP did not follow what you may have specifically requested. However, you avoided an office visit charge that would have occurred if you came separately. Not fraud, but it may be a physician who, like many these days, has a challenge keeping up with what are quite onerous insurance requirement.

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Re: Is General Practitioner Scamming Medicare

Post by core4portfolio » Tue Feb 05, 2019 2:08 pm

What a coincidence ....
Today I got bill from annual physicial check (wellness check) for my spouse.(not a medicare one)
There is a additional charge mentioned besised free well check covered by insurance.
I called Billing first then they explained its a office visit dedutible
I called the hospital - they mentioned if you discuss or even ask a question about something not covered as physical they charge it as doctor visit and have copay.
Spouse asked doctor just 1 question when doctor asked about if there is any questions.
we too never know that there is a copay for asking this question as they are considered as outside the physical exam .
I told them to escalate to office manager and waiting for their call.

Now I see car sales/service team is better than doc office atleast they inform us what they are going to charge.
Sad to say.. Doctor : once I most admired and most respected profession for me but it keep going went down the drain slowly.
YMMV
There might be very good doctors out there but i need to search a lot to find them
Last edited by core4portfolio on Tue Feb 05, 2019 2:38 pm, edited 1 time in total.
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Re: Is General Practitioner Scamming Medicare

Post by chessknt » Tue Feb 05, 2019 2:16 pm

Unless you specialize in medical coding (and your doctor sure doesnt) I'd be very carefully before alleging fraud
Medical billing is extraordinarily complex and just because something seems nonsensical or unfair doesn't mean it is either wrong or I tended to scam you. Most GPs offices run on razor thin margins and they have to capture every charge possible to stay afloat. Just because they haven't been captured in the past (ie you weren't charged for it before) does not mean the docor was not entitled to bill for it. Finally changes in you insurance this year may result in charges being passed on differently to you.

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Re: Is General Practitioner Scamming Medicare

Post by Rupert » Tue Feb 05, 2019 2:23 pm

The problem is with the medical billing codes and how Medicare and the ACA choose (or not) to define these things. Personally, I always expect to pay a co-pay when I see my GP. I have medical conditions, and I know they'll be discussed at every visit. I see specialists, and my GP has an obligation to follow what those specialists are doing to me. It's her job to coordinate care and make sure I'm not being prescribed medications that shouldn't mix, etc. I would question my GP's competence if she didn't ask for updates on all pre-existing conditions. Wouldn't you?

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Re: Is General Practitioner Scamming Medicare

Post by ERguy101 » Tue Feb 05, 2019 2:24 pm

core4portfolio wrote:
Tue Feb 05, 2019 2:08 pm
What a coincidence ....
Today I got bill from annual physicial check (wellness check) for my spouse.
There is a additional charge mentioned besised free well check covered by insurance.
I called Billing first then they explained its a office visit dedutible
I called the hospital - they mentioned if you discuss or even ask a question about something not covered as physical they charge it as doctor visit and have copay.
Spouse asked doctor just 1 question when doctor asked about if there is any questions.
we too never know that there is a copay for asking this question as they are considered as outside the physical exam .
I told them to escalate to office manager and waiting for their call.

Now I see car sales/service team is better than doc office atleast they inform us what they are going to charge.
Sad to say.. Doctor : once I most admired and most respected profession for me but it keep going went down the drain slowly.
YMMV
There might be very good doctors out there but i need to search a lot to find them
Respectfully, if the visit is just a medicare wellness visit, and your spouse asks unrelated questions, and eats up the doctors time, should he suck cost up? Would he then be admirable?

I know it all sucks. I work ER because I hate the billing aspect of medicine more than anything. It's terrible that Medicare has this visit that encourages no discussion about medical care between doctor and patient.

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dm200
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Re: Is General Practitioner Scamming Medicare

Post by dm200 » Tue Feb 05, 2019 2:28 pm

Being billed for "new issues", etc. for the "free"/no charge annual Medicare Wellness visit seems to be brought up here quite a bit.

In our Kaiser Medicare plan (been on medicare for eight years), if you read the "fine print", it is the same - you are billed if you bring up any new issues. However, to my pleasant surprise, my Kaiser PCP has never coded the visit such that I am billed the copay ;)

On one occasion, a situation developed a few days before my annual wellness appointment - and we spent 90% of the visit on that new issue.

Even if I were charged, it would only be $10 - since Kaiser reduced the PCP copay from $20 to $10 in 2019.

I always just scratch my head about this "rule" - if there is nothing wrong with you and you see the doctor, you are not charged. BUT - if there is something wrong with you, then you are charged. Seems backwards to me -- :confused

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Re: Is General Practitioner Scamming Medicare

Post by core4portfolio » Tue Feb 05, 2019 2:45 pm

ERguy101 wrote:
Tue Feb 05, 2019 2:24 pm
core4portfolio wrote:
Tue Feb 05, 2019 2:08 pm
What a coincidence ....
Today I got bill from annual physicial check (wellness check) for my spouse.
There is a additional charge mentioned besised free well check covered by insurance.
I called Billing first then they explained its a office visit dedutible
I called the hospital - they mentioned if you discuss or even ask a question about something not covered as physical they charge it as doctor visit and have copay.
Spouse asked doctor just 1 question when doctor asked about if there is any questions.
we too never know that there is a copay for asking this question as they are considered as outside the physical exam .
I told them to escalate to office manager and waiting for their call.

Now I see car sales/service team is better than doc office atleast they inform us what they are going to charge.
Sad to say.. Doctor : once I most admired and most respected profession for me but it keep going went down the drain slowly.
YMMV
There might be very good doctors out there but i need to search a lot to find them
Respectfully, if the visit is just a medicare wellness visit, and your spouse asks unrelated questions, and eats up the doctors time, should he suck cost up? Would he then be admirable?

I know it all sucks. I work ER because I hate the billing aspect of medicine more than anything. It's terrible that Medicare has this visit that encourages no discussion about medical care between doctor and patient.
Mine is not a medicare unlike OP. But the point is as a patient when doctor asking if there is any questions for you,
you may not know or atleast we dont know until now.... they are going to consider answering a question will be charged as office visit.
They dont have to give free consultation but they should let us know atleast so that it wont be surprise when bill comes.

Our kid's pediatrician told upfront when we went for physical exam and asked to check few thing... we dont have any surprise on the bill.
The transparency is issue in my perspective
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quantAndHold
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Re: Is General Practitioner Scamming Medicare

Post by quantAndHold » Tue Feb 05, 2019 2:52 pm

Every year when I go to the "wellness" appointment, I have to sign a piece of paper where I acknowledge that I might be billed for something if the doc does anything besides wellness, whatever that is.

Last year, everything was free, but the lab work turned up a diagnosis.

This year, I was charged for the same lab work, because I had an existing condition that was discussed.

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galeno
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Re: Is General Practitioner Scamming Medicare

Post by galeno » Tue Feb 05, 2019 4:24 pm

Medicare and private health care insurance companies WANT doctors to do this and bill for it. It supposedly promotes primary care. The concept has a fancy name (IIRC it's MACRA) but essentially it indicates that the doctor is "COMPLETE".

It drives my older USA physician colleagues crazy. They don't think like that. The younger doctors are used to it and do it naturally.

Actually the doctor might be PENALIZED for not doing this.
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Re: Is General Practitioner Scamming Medicare

Post by staythecourse » Tue Feb 05, 2019 4:37 pm

bengal22 wrote:
Tue Feb 05, 2019 1:47 pm
I would not call it fraud but definitely the doctor is trying to inflate charges.
Agreed. If he is a bit shady on billing I would wonder what else he/ she is shady with involving your care. Having trust in your doctor is the MOST important aspect of your care. No different then when I bring my car to the mechanic. I am assuming he has my best interest at heart and not my checkbook.

Good luck.
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Re: Is General Practitioner Scamming Medicare

Post by Thecallofduty » Tue Feb 05, 2019 4:58 pm

Hi

I think the advanced care planning is a requirement To be asked during wellness visit. Did not know it was a seperate charge though.

In regards to the gerd was it a problem addressed during the visit?
-thecallofduty

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Re: Is General Practitioner [billing Medicare correctly?]

Post by LadyGeek » Tue Feb 05, 2019 5:04 pm

I retitled the thread for clarity.

Please state your concerns in a civil, factual, manner.
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Re: Is General Practitioner [billing Medicare correctly?]

Post by international001 » Tue Feb 05, 2019 5:14 pm

Doctors are like mechanics. They have the power to information, so they charge as they please.

My physical exams (supposedly free), change based on the provider and on the number of tests they want to run. Routinely, they miss-code the same tests from one year to the next. If I complain hard enough, they'll change it. IT's not worth my time, but I do it as a hobby.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by Misenplace » Tue Feb 05, 2019 5:18 pm

How about a doctor who codes something that was not discussed? I discovered that mine was coding for a minor stress related issue that I had 4 years ago. I never brought it up again since it disappeared with the removal of stress, and neither did he ever ask me about it. But he coded it in the wellness exam for the last 3 years as continuing and managed. This year it was the single non-wellness code creating an extra office visit charge, so I dug deeper and found out what he was doing.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by Rupert » Tue Feb 05, 2019 5:20 pm

Misenplace wrote:
Tue Feb 05, 2019 5:18 pm
How about a doctor who codes something that was not discussed? I discovered that mine was coding for a minor stress related issue that I had 4 years ago. I never brought it up again since it disappeared with the removal of stress, and neither did he ever ask me about it. But he coded it in the wellness exam for the last 3 years as continuing and managed. This year it was the single non-wellness code creating an extra office visit charge, so I dug deeper and found out what he was doing.
Now that's an entirely different kettle of fish. That smells more fraudy.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by chessknt » Tue Feb 05, 2019 5:56 pm

To be clear, procedural codes that actually determine what you are being charged are not charged per issue. There is a complexity of visit that factors in to an office visit procedural code however a single problem 'being coded for' like anxiety may or may not influence that office visit code depending on documentation of data reviewed and the complexity or risk of other problems. If time is billed instead then it likely doesn't factor at all.

Like I said, unless this is an area you have experience in you need to acknowledge the limits of your understanding instead of jumping to conclusions of shady or fraudulent behavior. Thr people who do this professionally every day barely understand it because the rules ck stantly change and vary by insurer. I know the engineering types like to understand everything from how their TV works to the new tax code but some things are a bit too complicated to grasp from reading a few Internet articles and then trying to use logic, especially something as convoluted and politically tainted as cpt/icd coding.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by jcar » Tue Feb 05, 2019 6:12 pm

When I was new to Medicare (last year) I went in for the same physical as you. Got a bill for a few items as you describe that had just come up in conversation prompted by Dr. I called my Medicare Advantage plan, United Healthcare and told them. They contacted Dr directly and all charges were removed immediately. It's not reasonable for a routine physical not to discuss other things a specialist has or is tending to. The internists is supposed to have a complete picture of your health. Also my wife went in for a eye exam which was covered 100% and really got loaded up with stuff but the insurance company took care of it in the same way with her owing nothing.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by SevenBridgesRoad » Tue Feb 05, 2019 6:27 pm

Here's a pretty good explanation of the Medicare Annual Wellness Visit (AWV):

https://www.medicareinteractive.org/get ... ness-visit

I know many PCPs don't totally understand the AWV. This is a product (service) designed by Medicare with the best of intentions. Remember the old saying, "The road to Hell is paved with good intentions"? In reality it doesn't often work as designed. The customer (patient) doesn't confidently understand what they are buying (for no charge) and the doctor doesn't confidently understand what they are selling. Both parties are likely in the age old 'annual physical' mindset (and the AWV is clearly not an annual physical). Throw in an employer of the physician (often a large hospital system) with certain expectations and a coding department with lots of challenging rules...well, lots of failure modes and lots of ways for expectations to not be met.
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Re: Is General Practitioner [billing Medicare correctly?]

Post by LadyGeek » Tue Feb 05, 2019 6:58 pm

I removed an off-topic rant regarding (lack of) professional ethics.

Please state your concerns, in a civil, factual manner.
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Re: Is General Practitioner [billing Medicare correctly?]

Post by Broken Man 1999 » Tue Feb 05, 2019 7:25 pm

Frankly I hope my doctor bills for any service he provides to me. His is single doctor practice, and he has never made a nickle on my visits that wasn't richly deserved.

Of course with a $5 copay, it isn't like a co-pay will impoverish me.

But, simple solution for those complaining about having to pay a co-pay for asking questions: Don't ask questions. Don't worry about a nagging cough, upset stomach, numb limbs, migraine headaches, etc. Better to wait until conditions deteriorate and you are more apt to ensure your doctor "earns" that co-pay!

Hey, just self-diagnose using the 'net until you are sure of what is the matter with you, and be sure you tell your doctor about how you saved your co-pay on you wellness visit, but now the condition is deserving of a co-pay!

I just don't get the thought process I see here ! :confused

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Re: Is General Practitioner [billing Medicare correctly?]

Post by SevenBridgesRoad » Tue Feb 05, 2019 10:49 pm

jcar wrote:
Tue Feb 05, 2019 6:12 pm
When I was new to Medicare (last year) I went in for the same physical as you....
Respectfully, two problems with that statement, making the point that Medicare has created products (services) that are not confidently understood by (most) patients or (most) docs.

If you are new to Medicare, you are allowed a "Welcome to Medicare Preventive Visit". See link below. The Welcome to Medicare Visit is clearly NOT a physical. And it is NOT the same thing the OP went in for, an Annual Wellness Visit.

https://www.medicareinteractive.org/get ... tive-visit
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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Tue Feb 05, 2019 11:26 pm

If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?

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Re: Is General Practitioner [billing Medicare correctly?]

Post by Misenplace » Wed Feb 06, 2019 12:00 am

Rupert wrote:
Tue Feb 05, 2019 5:20 pm

Now that's an entirely different kettle of fish. That smells more fraudy
Yeah, I am looking for another doctor. I really don’t care about the extra hundred dollars I paid for the visit (which is the only reason I can think of for why it happened), but I do care that 1) my medical record is not accurate, and 2) now my medical record has a fictitious pre-existing condition. Not a problem under current Obamacare law, but who knows the future. Besides looking for another provider, also trying to get my record corrected. So far, provider is trying to pretend he didn’t fudge my record.

I’m not sure if this is a thing, but am posting it so that others are warned to explore the mysterious billing codes on their bill- there may be issues there to look into. I feel stupid for not doing it sooner since those codes actually have real life meaning. But the only way to figure it out is to get on the phone with either the billing office or your insurance.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by SevenBridgesRoad » Wed Feb 06, 2019 12:10 am

toofache32 wrote:
Tue Feb 05, 2019 11:26 pm
If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?
I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Wed Feb 06, 2019 1:25 am

SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am
toofache32 wrote:
Tue Feb 05, 2019 11:26 pm
If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?
I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."

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Re: Is General Practitioner [billing Medicare correctly?]

Post by SevenBridgesRoad » Wed Feb 06, 2019 1:43 am

toofache32 wrote:
Wed Feb 06, 2019 1:25 am
SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am
toofache32 wrote:
Tue Feb 05, 2019 11:26 pm
If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?
I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
Super impressed. I believe you hit the nail smack on the head. The paragraph you quoted and the observation “they see free and don’t bother...” are at the crux of the issue. Patients want the free thing but not the free thing Medicare is actually offering. And I agree with them...it’s a pretty limited offering as designed, although I can see the good intentions. Then combine that with (most) physicians don’t understand the product Medicare wants them to provide and aren’t trained or inculcated to deliver it.

Back to the OP (or are they TAs now?). Unlikely fraud or greed. Very likely a lot of misaligned, unspoken expectations.
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Re: Is General Practitioner [billing Medicare correctly?]

Post by pdavi21 » Wed Feb 06, 2019 2:32 am

Imagine if there was no copay. Would you care that your doctor is defrauding (ethically if not legally) Medicare? Do you think the average person would? Good thing they have the copays...
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Re: Is General Practitioner [billing Medicare correctly?]

Post by Nate79 » Wed Feb 06, 2019 7:40 am

toofache32 wrote:
Wed Feb 06, 2019 1:25 am
SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am
toofache32 wrote:
Tue Feb 05, 2019 11:26 pm
If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?
I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?

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Re: Is General Practitioner [billing Medicare correctly?]

Post by RickBoglehead » Wed Feb 06, 2019 7:55 am

While not a Medicare issue, I experienced something similar in my annual checkup. I told the doctor I wanted to get a skin tag removed (they simply snip it with scissors. He said I needed to make another appointment. No problem, did that.

At the appointment, he came in and handed me a piece of paper that said that the procedure (pull with tweezers, snip with scissors, hand patient gauze pad to apply pressure) might not be covered, and it would be $135. That's in addition to the office visit he's being paid for. No mention of this during the first visit, they waited until I was in the room. I looked at the paper, and said to him, "there was no mention of this when you told me to make another appointment, nor when I made the appointment and told them the purpose of it." He replied "fine, I will eat it" and took the paper away.
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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Wed Feb 06, 2019 8:14 am

RickBoglehead wrote:
Wed Feb 06, 2019 7:55 am
While not a Medicare issue, I experienced something similar in my annual checkup. I told the doctor I wanted to get a skin tag removed (they simply snip it with scissors. He said I needed to make another appointment. No problem, did that.

At the appointment, he came in and handed me a piece of paper that said that the procedure (pull with tweezers, snip with scissors, hand patient gauze pad to apply pressure) might not be covered, and it would be $135. That's in addition to the office visit he's being paid for. No mention of this during the first visit, they waited until I was in the room. I looked at the paper, and said to him, "there was no mention of this when you told me to make another appointment, nor when I made the appointment and told them the purpose of it." He replied "fine, I will eat it" and took the paper away.
If it’s just snipping, why didn’t you do it yourself at home? Serious question.
I'm still trying to understand the problem here. You are objecting to the doctor and his staff getting paid for their services?
Last edited by toofache32 on Wed Feb 06, 2019 8:47 am, edited 1 time in total.

anil686
Posts: 933
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Re: Is General Practitioner [billing Medicare correctly?]

Post by anil686 » Wed Feb 06, 2019 8:27 am

This is (IMHO) one of the big problems with medicine being taken away from individuals and their physicians and centralized with corporate centers. The OP called the hospital (I presume b/c the practice is a hospital owned practice) who informs the OP of the policy. I am sure the hospital has billing specialists (if they are anything like the billing specialists at our hospital) meet with physicians every other week to scold them for consistent underbilling and "educating" them of the codes, how to bill appropriately for services rendered and violation of the law for underbilling (yes that is a thing called inducement).

When I started in medicine 25 years ago- an annual physical was an opportunity to review the health of the patient for the previous year and anticipate a plan for the upcoming year. It was not designed to be a visit where I handled a cold, flu, or ear ache because there is not time for that and it disrupts the purpose of the meeting. Corporate medicine has said that is not what should be done, scolds doctors that still do extras with the annual exam and is commoditizing time and services. I think younger patients have less of an issue with this because it has been transitioning to this for years. But I see older patients, especially those on Medicare who remember experiences during their working years, as having a hard time with entities setting firm boundaries. about 10 years ago, (for the first time in the US) a majority of physicians are employed. Physicians are no longer holding the bag for non payments or uncovered services. That would be the owners of the companies that hire physicians (namely hospitals, clinic groups, etc). Patients need to expect that more onerous collection and more stringent policies will come into effect as the entities responsible for collecting are corporations and "non profits" - not their physician in large part who has an established relationship with them. JMO though...

SimonJester
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Re: Is General Practitioner [billing Medicare correctly?]

Post by SimonJester » Wed Feb 06, 2019 8:30 am

This is fallout from the The Electronic Medical Records (EMR) Mandate. Your DR is now sitting behind a laptop checking boxes and filling out a form during your visit vs interacting with you the patient. This was pushed by big health care corporations and insurance companies. It did not create the desired effect of sharing health care information between providers because each hospital, DR office, & clinic uses their own version so software and none of them interface with each other.

Dr. Zubin Damania, has a great you tube video on the topic https://youtu.be/3TveJLAi_y4

I have complained about this in the past, you now need to expect to pay an office visit for that "free" annual exam. The "free" annual exam was created to try and get patients to goto their DR every year and catch health issues before they became larger problems. The practice of billing for everything outside the narrow parameters of the "free" visit will only discourage patients from going to the annual visit.

DRs. need to take back their profession, time to stop all this insurance BS and bill by the hour.
"They who can give up essential liberty to obtain a little temporary safety, deserve neither liberty nor safety." - Benjamin Franklin

toofache32
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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Wed Feb 06, 2019 8:35 am

Nate79 wrote:
Wed Feb 06, 2019 7:40 am
toofache32 wrote:
Wed Feb 06, 2019 1:25 am
SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am
toofache32 wrote:
Tue Feb 05, 2019 11:26 pm
If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?
I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?
The doc?? What makes you think the doc knows where the line is drawn? He/she is a doctor, not a coder. It's the PATIENT's insurance, not the doctors.
What would be wrong with the patient actually taking ownership of the policy they bought and trying to understand it? The same information available to the doctor is available to the patient.

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8foot7
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Re: Is General Practitioner [billing Medicare correctly?]

Post by 8foot7 » Wed Feb 06, 2019 8:46 am

toofache32 wrote:
Wed Feb 06, 2019 8:35 am
Nate79 wrote:
Wed Feb 06, 2019 7:40 am
toofache32 wrote:
Wed Feb 06, 2019 1:25 am
SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am
toofache32 wrote:
Tue Feb 05, 2019 11:26 pm
If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?
I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?
The doc?? What makes you think the doc knows where the line is drawn? He/she is a doctor, not a coder. It's the PATIENT's insurance, not the doctors.
What would be wrong with the patient actually taking ownership of the policy they bought and trying to understand it? The same information available to the doctor is available to the patient.
Because the patient has no control over when the doctor crosses that line into a discussion over a new issue. Are we supposed to sit in the exam room and say "lalalalalala please tell me nothing I can't know for free" or otherwise stop the doctor? Or say up front, doc, do nothing that would compromise the 100% covered nature of this visit.

And come on, this isn't an obscure insurance contract, this is f$%$(ing Medicare. Your point would stand if it was East Iowan Archeological Diggers Association Self-Funded Medical Care Plan. Doctors on staff have to know about this, and if they don't, they need to get educated.

rantk81
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Re: Is General Practitioner [billing Medicare correctly?]

Post by rantk81 » Wed Feb 06, 2019 8:48 am

As a patient, the line between "preventative" and "regular visit" is quite grey to me.

I always like to schedule my "wellness/preventative" visit early in the calendar year, to get familiar with a doctor, and see if there are any health issues that I can consider when making the decision of "is this probably going to be a high or low out of pocket medical spending year".

My employer sponsored insurance has changed doctor networks for a few years in a row, requiring me to pick a new doctor each of the last two years.
Both of my "wellness" visits with each of those two new doctors each lasted nearly an hour, and was extremely thorough. It included a discussion of my entire medical history and family history. Even sometimes resulted in changing prescriptions.

Both times, those were coded with a CPT code of 99385 which is described on another website as:
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient.

Each time, my insurance covered the doctor visit at 100% preventative, including most of the tests that were ordered from it.
From the description of the CPT code, it sounds pretty accurate to what services I received. However, I'm just glad that the insurance company that is processing the claims is considering that to be covered 100% before my deductible! Maybe they are being more generous to me than they have to? Or maybe the doctors are under-billing/under-coding in both cases?

toofache32
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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Wed Feb 06, 2019 8:56 am

8foot7 wrote:
Wed Feb 06, 2019 8:46 am
toofache32 wrote:
Wed Feb 06, 2019 8:35 am
Nate79 wrote:
Wed Feb 06, 2019 7:40 am
toofache32 wrote:
Wed Feb 06, 2019 1:25 am
SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am


I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?
The doc?? What makes you think the doc knows where the line is drawn? He/she is a doctor, not a coder. It's the PATIENT's insurance, not the doctors.
What would be wrong with the patient actually taking ownership of the policy they bought and trying to understand it? The same information available to the doctor is available to the patient.
Because the patient has no control over when the doctor crosses that line into a discussion over a new issue. Are we supposed to sit in the exam room and say "lalalalalala please tell me nothing I can't know for free" or otherwise stop the doctor? Or say up front, doc, do nothing that would compromise the 100% covered nature of this visit.

And come on, this isn't an obscure insurance contract, this is f$%$(ing Medicare. Your point would stand if it was East Iowan Archeological Diggers Association Self-Funded Medical Care Plan. Doctors on staff have to know about this, and if they don't, they need to get educated.
Yes. It's YOUR insurance, not the doctors. Take ownership of it.

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8foot7
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Re: Is General Practitioner [billing Medicare correctly?]

Post by 8foot7 » Wed Feb 06, 2019 9:45 am

toofache32 wrote:
Wed Feb 06, 2019 8:56 am
8foot7 wrote:
Wed Feb 06, 2019 8:46 am
toofache32 wrote:
Wed Feb 06, 2019 8:35 am
Nate79 wrote:
Wed Feb 06, 2019 7:40 am
toofache32 wrote:
Wed Feb 06, 2019 1:25 am


I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?
The doc?? What makes you think the doc knows where the line is drawn? He/she is a doctor, not a coder. It's the PATIENT's insurance, not the doctors.
What would be wrong with the patient actually taking ownership of the policy they bought and trying to understand it? The same information available to the doctor is available to the patient.
Because the patient has no control over when the doctor crosses that line into a discussion over a new issue. Are we supposed to sit in the exam room and say "lalalalalala please tell me nothing I can't know for free" or otherwise stop the doctor? Or say up front, doc, do nothing that would compromise the 100% covered nature of this visit.

And come on, this isn't an obscure insurance contract, this is f$%$(ing Medicare. Your point would stand if it was East Iowan Archeological Diggers Association Self-Funded Medical Care Plan. Doctors on staff have to know about this, and if they don't, they need to get educated.
Yes. It's YOUR insurance, not the doctors. Take ownership of it.
The doctor or his office agreed to accept a Medicare thereby placing some onus (we can argue how much) on the doctor or his office to understand these things. The doctor ought to take ownership of understanding coding and its consequences. And last I checked Medicare Part A wasn’t really all that optional so it’s not really “my” insurance either; it’s sort of all of ours.

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Nate79
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Location: Delaware

Re: Is General Practitioner [billing Medicare correctly?]

Post by Nate79 » Wed Feb 06, 2019 9:55 am

toofache32 wrote:
Wed Feb 06, 2019 8:35 am
Nate79 wrote:
Wed Feb 06, 2019 7:40 am
toofache32 wrote:
Wed Feb 06, 2019 1:25 am
SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am
toofache32 wrote:
Tue Feb 05, 2019 11:26 pm
If you intend to have a "wellness" visit, but you are not "well" and have comorbidities, then what exactly are you wanting from this visit other than a freebie? If problems (old or new) are realized, do you want them ignored?
I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?
The doc?? What makes you think the doc knows where the line is drawn? He/she is a doctor, not a coder. It's the PATIENT's insurance, not the doctors.
What would be wrong with the patient actually taking ownership of the policy they bought and trying to understand it? The same information available to the doctor is available to the patient.
If I book a visit for X purpose I expect to receive the X purpose and the doc to understand when the visit has crossed outside of the defined X purpose which will involve additional codes. Perhaps I misunderstand but after a visit is complete who is the one that is deciding what the visit covered and if the visit involved more than the pre-agreed visit of X? I am not saying anything about whether the insurance company pays or not for the visit of X and any additional items but we should be informed when the visit goes beyond the original purpose of the visit. I don't agree that it is the patients responsibility to understand where is that line (between original booking purpose and additional items) because clearly there is ZERO uniform application of the rules.

This has nothing to do with insurance and everything to do with disclosure ahead of time before something is done that may/may not incur additional charges. The consumer should be informed except in case of emergency which this is clearly not.

Docs blame insurance. Insurance blames the medical industry/docs. As consumers we are left in the middle but it is really clear in this thread and every discussion the biases of one side vs the other in the discussions. In no other industry would this business behaviour be allowed on BOTH sides.

staythecourse
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Re: Is General Practitioner [billing Medicare correctly?]

Post by staythecourse » Wed Feb 06, 2019 10:04 am

Not sure why all the bickering on this one. Seems pretty clear cut. Patient Smith makes appointment for wellness visit. Patient Smith goes to appointment and only discusses issues that have to deal with wellness visit. Patient Smith should only get billed for wellness visit. IF patient Smith brought up HIMSELF other issues that are outside of wellness visit then he/ she should get billed. If not then no he/ she should not get billed and find it unethical to do so. You can't add fries to an order when someone just asks for a burger and expect them to be okay with paying for the fries.

I'm a physician and have no problem calling out other docs who are shady. Self policing is important is any industry and without it lends to unethical behavior that makes everyone in the field look bad. There are unethical doctors, lawyers, priests, teachers, etc... No field is immune. Good for the OP to ask questions. I know when I practice what I am doing is ethical and legal as I know billing pretty well. The few times patients have asked I am the one who tells them to call their insurance to get clarification if it is a billing issue or a second opinion if it is a medical decision issue.

Good luck.
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toofache32
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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Wed Feb 06, 2019 10:20 am

Nate79 wrote:
Wed Feb 06, 2019 9:55 am
toofache32 wrote:
Wed Feb 06, 2019 8:35 am
Nate79 wrote:
Wed Feb 06, 2019 7:40 am
toofache32 wrote:
Wed Feb 06, 2019 1:25 am
SevenBridgesRoad wrote:
Wed Feb 06, 2019 12:10 am


I share your dismay. But these are the products Medicare has created. Look at the links if you get a chance. The bullet points are very specific. These products (services) are clearly intended to be something other than an annual physical exam and a discussion of illness.
I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?
The doc?? What makes you think the doc knows where the line is drawn? He/she is a doctor, not a coder. It's the PATIENT's insurance, not the doctors.
What would be wrong with the patient actually taking ownership of the policy they bought and trying to understand it? The same information available to the doctor is available to the patient.
If I book a visit for X purpose I expect to receive the X purpose and the doc to understand when the visit has crossed outside of the defined X purpose which will involve additional codes. Perhaps I misunderstand but after a visit is complete who is the one that is deciding what the visit covered and if the visit involved more than the pre-agreed visit of X? I am not saying anything about whether the insurance company pays or not for the visit of X and any additional items but we should be informed when the visit goes beyond the original purpose of the visit. I don't agree that it is the patients responsibility to understand where is that line (between original booking purpose and additional items) because clearly there is ZERO uniform application of the rules.

This has nothing to do with insurance and everything to do with disclosure ahead of time before something is done that may/may not incur additional charges. The consumer should be informed except in case of emergency which this is clearly not.

Docs blame insurance. Insurance blames the medical industry/docs. As consumers we are left in the middle but it is really clear in this thread and every discussion the biases of one side vs the other in the discussions. In no other industry would this business behaviour be allowed on BOTH sides.
The coder decides this.
Look, your "wellness" visit requires checking basic things like blood pressure. If your blood pressure is found to be high, then you are not "well". That's where this turns in a different direction.

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8foot7
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Re: Is General Practitioner [billing Medicare correctly?]

Post by 8foot7 » Wed Feb 06, 2019 10:23 am

toofache32 wrote:
Wed Feb 06, 2019 10:20 am

The coder decides this.
Look, your "wellness" visit requires checking basic things like blood pressure. If your blood pressure is found to be high, then you are not "well". That's where this turns in a different direction.
So you're saying I can order a free wellness hamburger, and perhaps even get a tray with that free wellness hamburger on it and sit down, but the minute I decide to actually eat the free wellness hamburger, I am given a side order of fries that I didn't request and now have to pay for.

Broken Man 1999
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Re: Is General Practitioner [billing Medicare correctly?]

Post by Broken Man 1999 » Wed Feb 06, 2019 10:26 am

There is a very nice government publication (Medicare and You) that provides any Medicare recipient with some really good information.

Perhaps perusing this publication would be a good idea to help eliminate issues/questions.

The particular issue under discussion is explained on page 48 for your "Welcome to Medicare" preventative visit, and on page 49 for your yearly "Wellness Visit".

After describing the visit, there is a large blue arrow pointing to the following text: If your doctor or other health care provider performs additional tests or services during the same visit that aren't covered under this preventative benefit, you may have to pay coinsurance and the Part B deductible may apply.

I should think that on average forum members should be well aware of what take $$ from their pockets, considering their usual desire of squeezing every nickle of costs possible out of a wide-ranging variety of products and service.

Applying the same zeal to minimize health care spending should be a natural fit, no?

Why some want to stiff their doctor is a mystery. I would much rather pay a co-pay during my wellness visit instead of having to visit my doctor again to address possible items of interest to both of us.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven than I shall not go. " -Mark Twain

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Nate79
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Re: Is General Practitioner [billing Medicare correctly?]

Post by Nate79 » Wed Feb 06, 2019 10:28 am

staythecourse wrote:
Wed Feb 06, 2019 10:04 am
Not sure why all the bickering on this one. Seems pretty clear cut. Patient Smith makes appointment for wellness visit. Patient Smith goes to appointment and only discusses issues that have to deal with wellness visit. Patient Smith should only get billed for wellness visit. IF patient Smith brought up HIMSELF other issues that are outside of wellness visit then he/ she should get billed. If not then no he/ she should not get billed and find it unethical to do so. You can't add fries to an order when someone just asks for a burger and expect them to be okay with paying for the fries.

I'm a physician and have no problem calling out other docs who are shady. Self policing is important is any industry and without it lends to unethical behavior that makes everyone in the field look bad. There are unethical doctors, lawyers, priests, teachers, etc... No field is immune. Good for the OP to ask questions. I know when I practice what I am doing is ethical and legal as I know billing pretty well. The few times patients have asked I am the one who tells them to call their insurance to get clarification if it is a billing issue or a second opinion if it is a medical decision issue.

Good luck.
The problem is that most people do not know what is included/not included nor even where to look to understand what is the line between a wellness visit and not nor whether a doc will include or not include something as wellness visit or not. In every one of my wellness visits there is back and forth discussion with the doc and you never know where is the line. I was lucky so far and the doc never coded something extra and when a new issue did come up discussing that issue would require a follow-up visit (which would clearly then be not a wellness visit). Perhaps for Medicare there are clear documents but outside that how do I know?

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Re: Is General Practitioner [billing Medicare correctly?]

Post by SevenBridgesRoad » Wed Feb 06, 2019 10:30 am

This thread has moved pretty far afield from the OP’s question and is firmly into “what’s wrong with health care today” territory. I think by the responses so far one can see there are plenty of problems and misunderstandings and folks to blame for the mess.

Back to the OP’s question: very unlikely to be fraud.

As to the back and forth on who should do what, I’m a fan of the circle of control concept.

You can control what you do and what you know. You have zero control over things like, “the doc oughta be educated on coding”, even if that’s true. I happen to believe we should, but lots of my colleagues disagree. You have no control over what the doc believes should happen. You do have control over what you learn: as painful as it might be, you can educate yourself a bit more on your health care insurance (Medicare), in the same way you’ve learned about complex subjects like SoR and SWRs or financial advisors (there may be a nice parallel here about walking into a FAs office with little or no knowledge: you might end up surprised and disappointed with what you get sold.)

With regular Medicare most of us have control over which doc we see. That would be an actionable way to have some control over the coding and product knowledge of the doc. You do have control over a conversation with the doc about what your expectations are. I realize none of this is easy, and maybe it’s not how it oughta be.
Last edited by SevenBridgesRoad on Wed Feb 06, 2019 10:32 am, edited 1 time in total.
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samsoes
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Re: Is General Practitioner [billing Medicare correctly?]

Post by samsoes » Wed Feb 06, 2019 10:31 am

toofache32 wrote:
Wed Feb 06, 2019 8:56 am
8foot7 wrote:
Wed Feb 06, 2019 8:46 am
toofache32 wrote:
Wed Feb 06, 2019 8:35 am
Nate79 wrote:
Wed Feb 06, 2019 7:40 am
toofache32 wrote:
Wed Feb 06, 2019 1:25 am


I agree but I am truly wondering what the general public is expecting from this? They see "free" and don't bother reading the details. What does a patient expect when a problem is found, ignore it?

"During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit."
So what would be wrong with the doc informing the patient when the line is crossed between the booked purpose of the visit and additional coding that may result in additional charges?
The doc?? What makes you think the doc knows where the line is drawn? He/she is a doctor, not a coder. It's the PATIENT's insurance, not the doctors.
What would be wrong with the patient actually taking ownership of the policy they bought and trying to understand it? The same information available to the doctor is available to the patient.
Because the patient has no control over when the doctor crosses that line into a discussion over a new issue. Are we supposed to sit in the exam room and say "lalalalalala please tell me nothing I can't know for free" or otherwise stop the doctor? Or say up front, doc, do nothing that would compromise the 100% covered nature of this visit.

And come on, this isn't an obscure insurance contract, this is f$%$(ing Medicare. Your point would stand if it was East Iowan Archeological Diggers Association Self-Funded Medical Care Plan. Doctors on staff have to know about this, and if they don't, they need to get educated.
Yes. It's YOUR insurance, not the doctors. Take ownership of it.
Sir, are you aware of all the covered perils and detailed exclusions on your home and auto insurance policies, and the detailed legalistic definitions of "your covered auto" and "permissive user?"

After all, it's your insurance, not the body shop's.
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