Is General Practitioner [billing Medicare correctly?]

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

Post by SlowMovingInvestor » Wed Feb 06, 2019 11:28 am

This may depend on particular practice/physician. I generally go over ongoing health issues (mostly minor in my case) with my doctor during annual exam, and he only charges for the annual visit (which is fully covered).

It might be different if I had a particular problem (say a fever or an injury) at annual exam time, but that hasn't happened yet.

ADDED: I should clarify that I'm not on Medicare.
Last edited by SlowMovingInvestor on Wed Feb 06, 2019 11:39 am, edited 1 time in total.

Good Listener
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Re: Is General Practitioner [billing Medicare correctly?]

Post by Good Listener » Wed Feb 06, 2019 11:34 am

the doctor did OP afavor. The Medicare wellness visit is extremely limited and really does not involve any physical exam except blood pressure, so by adding a diagnostic code for the other symptom then Medicare covers that. Otherwise your doctor could not discuss anything. I have no idea what co-pays people are talking about unless it is the 20% for which most of us have a supplement. Medicare is exactly opposite of health plans in ages before Medicare ....preventive care and labs are covered prior to Medicare by law. Medicare covers no preventive care except for that very limited bunch of wellness questions.

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

Post by Broken Man 1999 » Wed Feb 06, 2019 1:42 pm

Good Listener wrote:
Wed Feb 06, 2019 11:34 am
the doctor did OP afavor. The Medicare wellness visit is extremely limited and really does not involve any physical exam except blood pressure, so by adding a diagnostic code for the other symptom then Medicare covers that. Otherwise your doctor could not discuss anything. I have no idea what co-pays people are talking about unless it is the 20% for which most of us have a supplement. Medicare is exactly opposite of health plans in ages before Medicare ....preventive care and labs are covered prior to Medicare by law. Medicare covers no preventive care except for that very limited bunch of wellness questions.
Actually Medicare provides for many preventative care services, starting with Abdominal aortic aneurysm screening to Smoking and tobacco-use cessation counseling...

For a look at the extensive preventative care, consult your copy of Medicare and You, I have the paper edition, so I don't know about the page formatting for the online version, so page numbers are only good for the 2019 paper edition.

The extensive preventative services list starts on page 30, and goes to page 49.

Seriously, check it out.

Also consider the lengthy list of Medicare approved immunizations!

Broken Man 1999
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toofache32
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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Wed Feb 06, 2019 1:43 pm

8foot7 wrote:
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.
Yes, per Medicare rules. At least that's how I interpret them in the above links. Do you interpret them differently?

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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Wed Feb 06, 2019 1:45 pm

samsoes wrote:
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

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.
No. And neither is the body shop. But I don't blame the body shop for rules created by my crappy insurance policy.
Look, I don't have a good answer for how to deal with this. But the party line here is to always blame the doctor. Everyone thinks the doctor is the boss. Everyone thinks the doctor has authority. Everyone thinks the doctor is responsible for everything including the billing that someone else does.
In most Medicare practices, the doctor is just an employee like the front desk lady. Take it up with Medicare and the person that does the billing.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by SevenBridgesRoad » Wed Feb 06, 2019 2:24 pm

Here's a patient flyer produced by the American Academy Of Family Physicians. AAFP recommends that physician practices provide these to patients and have a discussion with them about what is included and what is not. I doubt many practices actually do this. But for purposes of this discussion, we on the forum can use this to better understand what is intended for the AWV.

https://www.aafp.org/dam/AAFP/documents ... o-Know.pdf


Then for those who want more detail, here is a page from the AAFP website directed at physicians and their staff.

https://www.aafp.org/practice-managemen ... s/awv.html


Right or wrong, I can tell you most docs would get a third of the way down this page and say this is pretty crazy. And if larger organizations try to educate the docs on this (some do), you can see this would be a mind-numbing PowerPoint. We all know that a couple hour PP presentation doesn't change habits and mindsets. And, all physicians spent years of training to perform an annual physical, and talking about problems is second nature. Patients also understand the annual physical dance and know discussing problems is part of it.

So again, while well-intended, the Medicare AWV is a relatively new product (service) over-laid on an existing dance between patient and doc, with neither party confidently understanding how to manage the old dance with new expectations. No wonder this is not trouble-free.
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brennok
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Re: Is General Practitioner Scamming Medicare

Post by brennok » Wed Feb 06, 2019 11:28 pm

Thecallofduty wrote:
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?
There is but there are certain qualifications you have to meet. I believe the CPT is 99497. now there is a category 2 cose also that covers it depending on which qualifications you hit. Category 2 codes don’t get paid but fall under the reporting programs. OP didnt mention the codes so it could be either.

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dm200
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Re: Is General Practitioner [billing Medicare correctly?]

Post by dm200 » Thu Feb 07, 2019 1:55 pm

Since, I believe, the "no charge" annual visit applies to both those on Original Medicare and those on Medicare Advantage (MA) plans, I wonder if the same issue comes up with those on MA plans?

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Paulie
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Re: Is General Practitioner Scamming Medicare

Post by Paulie » Thu Feb 07, 2019 5:56 pm

brennok wrote:
Wed Feb 06, 2019 11:28 pm
Thecallofduty wrote:
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?
There is but there are certain qualifications you have to meet. I believe the CPT is 99497. now there is a category 2 cose also that covers it depending on which qualifications you hit. Category 2 codes don’t get paid but fall under the reporting programs. OP didnt mention the codes so it could be either.
GP is fully aware of GI prob and that local GI Dr treats it.
He simply asked if I was still taking the meds for it and that was all.

His billing clerk "padded" the bill. Sorry my take.

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eye.surgeon
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Re: Is General Practitioner [billing Medicare correctly?]

Post by eye.surgeon » Thu Feb 07, 2019 6:00 pm

If your doctor documents "wellness exam" with no medical issues addressed, your visit will be denied by medicare, you get the bill, and you place an angry call to his billing office complaining that the doctor ripped you off and you refuse to pay the bill.

If the doctor (correctly) documents your medical issues, you accuse him of padding the bill.

Which would you prefer to complain about?
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SevenBridgesRoad
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Re: Is General Practitioner [billing Medicare correctly?]

Post by SevenBridgesRoad » Thu Feb 07, 2019 6:09 pm

eye.surgeon wrote:
Thu Feb 07, 2019 6:00 pm
If your doctor documents "wellness exam" with no medical issues addressed, your visit will be denied by medicare, you get the bill, and you place an angry call to his billing office complaining that the doctor ripped you off and you refuse to pay the bill.

If the doctor (correctly) documents your medical issues, you accuse him of padding the bill.

Which would you prefer to complain about?
This would be true, except for once a year Medicare Annual Wellness Visit and the first time Welcome to Medicare Visit.
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westie
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Re: Is General Practitioner [billing Medicare correctly?]

Post by westie » Thu Feb 07, 2019 9:05 pm

This is no different than taking your car to a repair shop for "free" a 32 point inspection, whatever they find, they'll be happy to set up another appointment to repair the damage. They don't "fix it" during the inspection.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Thu Feb 07, 2019 9:08 pm

westie wrote:
Thu Feb 07, 2019 9:05 pm
This is no different than taking your car to a repair shop for "free" a 32 point inspection, whatever they find, they'll be happy to set up another appointment to repair the damage. They don't "fix it" during the inspection.
Except....this scenario was created by YOUR auto insurance company.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Thu Feb 07, 2019 9:17 pm

SevenBridgesRoad wrote:
Thu Feb 07, 2019 6:09 pm
eye.surgeon wrote:
Thu Feb 07, 2019 6:00 pm
If your doctor documents "wellness exam" with no medical issues addressed, your visit will be denied by medicare, you get the bill, and you place an angry call to his billing office complaining that the doctor ripped you off and you refuse to pay the bill.

If the doctor (correctly) documents your medical issues, you accuse him of padding the bill.

Which would you prefer to complain about?
This would be true, except for once a year Medicare Annual Wellness Visit and the first time Welcome to Medicare Visit.
I'm still trying to figure out what this is. If you are "well" then why do you need a doctor??
I suspect there are many patients who feel they are "well" but get angry when they learn their blood pressure is high and have to pay to manage it.
And how many people over 65 really think they have no health issues??
Last edited by toofache32 on Thu Feb 07, 2019 9:31 pm, edited 1 time in total.

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

Post by toofache32 » Thu Feb 07, 2019 9:31 pm

This link seems to tell if you area a Medicare recipient who qualifies for this:

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

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Re: Is General Practitioner [billing Medicare correctly?]

Post by Nate79 » Thu Feb 07, 2019 9:34 pm

westie wrote:
Thu Feb 07, 2019 9:05 pm
This is no different than taking your car to a repair shop for "free" a 32 point inspection, whatever they find, they'll be happy to set up another appointment to repair the damage. They don't "fix it" during the inspection.
It's more like after the 32 point inspection the mechanic asks "has the transmission been running smooth?" And you say yes but it has some jerkiness every once in a while. Mechanic says you should make an appt and we can check it out and 3 weeks later you get a bill for $200 without any warning or discussion about prices coded as an item not included in the 32 point inspection was discussed.

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

Post by toofache32 » Thu Feb 07, 2019 9:41 pm

8foot7 wrote:
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

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.
Not at the rates paid by Medicare. I find it truly fascinating that MOST Medicare patient think they have GREAT insurance and have no idea how low the reimbursement is, and have no idea how this affects their healthcare. When I was a Medicare doctor, it was amazing how these patients would just plop their entitled rears in my chair and say "fix me." They actually expected premium service at a SEVERE discount. As a surgical specialist, Medicare fees are 25% of my fees on average. Which bogleheads here would be happy to work for a 75% pay cut?

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

Post by toofache32 » Thu Feb 07, 2019 9:44 pm

Nate79 wrote:
Thu Feb 07, 2019 9:34 pm
westie wrote:
Thu Feb 07, 2019 9:05 pm
This is no different than taking your car to a repair shop for "free" a 32 point inspection, whatever they find, they'll be happy to set up another appointment to repair the damage. They don't "fix it" during the inspection.
It's more like after the 32 point inspection the mechanic asks "has the transmission been running smooth?" And you say yes but it has some jerkiness every once in a while. Mechanic says you should make an appt and we can check it out and 3 weeks later you get a bill for $200 without any warning or discussion about prices coded as an item not included in the 32 point inspection was discussed.
I took my car for the 32 point inspection. The mechanic had the NERVE to tell me my fluids were low!! And he even wanted to charge me MONEY to replace those fluids!! I'm taking my business elsewhere to find someone else who will work for free!

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Re: Is General Practitioner Scamming Medicare

Post by jayk238 » Thu Feb 07, 2019 10:49 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.(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
Its unfortunate that your doctor doesnt inform you but i do.
However its not his fault and you are making a truly false equivalence. When you go to the car dealer is there a third party (insurer) involved in charging the price or setting? No. Do you ask your car dealer the price before buying a car? Yes.
So did you ask your doctor the price of the visit? Probably NO.
Did you ask if the insurer will cover this service? Maybe but that doesnt equal asking the doctor.
But why dont we ask the doctor? Because we go through the insurer. Your doctor may see 20 pt a day. Should he know all the charges for all the insurances?
So next time you want a fair answer ask your doctor directly first just as you ask your store clerk the price of an item you are unsure of before buying

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Re: Is General Practitioner [billing Medicare correctly?]

Post by jayk238 » Thu Feb 07, 2019 10:52 pm

My general line when i see a new pt is-

‘my wife is a patient like you and doesnt like surprise charges, she doesnt mind being charged for services but wants to be told first so she told me i should inform you before hand as well. i want u to know that generally annual physicals are covered but dont reflect new issues. Since you are here for a new issue i want u to know there may be an additional charge. Please let me know if this is ok’

That usually takes care of it

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Re: Is General Practitioner [billing Medicare correctly?]

Post by jayk238 » Thu Feb 07, 2019 10:58 pm

toofache32 wrote:
Thu Feb 07, 2019 9:17 pm
SevenBridgesRoad wrote:
Thu Feb 07, 2019 6:09 pm
eye.surgeon wrote:
Thu Feb 07, 2019 6:00 pm
If your doctor documents "wellness exam" with no medical issues addressed, your visit will be denied by medicare, you get the bill, and you place an angry call to his billing office complaining that the doctor ripped you off and you refuse to pay the bill.

If the doctor (correctly) documents your medical issues, you accuse him of padding the bill.

Which would you prefer to complain about?
This would be true, except for once a year Medicare Annual Wellness Visit and the first time Welcome to Medicare Visit.
I'm still trying to figure out what this is. If you are "well" then why do you need a doctor??
I suspect there are many patients who feel they are "well" but get angry when they learn their blood pressure is high and have to pay to manage it.
And how many people over 65 really think they have no health issues??
The once a year AWV or annual wellness visit does not cover a physical exam. It does not cover new issues. It covers going over how they generally feel and their current medications. It goes over a few other non medical issues/medico legal etc. its pretty simple really. Go to your doc for something new or a complaint and you can expext a charge.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by jayk238 » Thu Feb 07, 2019 11:08 pm

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.
I disagree. This stuff happens everywhere its just that the end consumer usually doesnt deal with it. That product you bought at the grocery store? Lots of grocery stores purposefully squeeze suppliers by not paying them. Its a way to hold them hostage for futurr discounts. It happens everywhere. And every one blames someone else. The consumer is largely avoided in this game. In medicine its thr billing shenanigans but because of the way you use it - via insurance you are acutely aware. It may not be the same analogy as the above example but thats not to say other business dont face issues.

Its just that medicine is the only insurance product used regularly. How many people and how often do they exercise their insurance for auto or home? Its rare so its not griefed upon as often

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Re: Is General Practitioner [billing Medicare correctly?]

Post by AkwardDoct@rd » Fri Feb 08, 2019 12:50 am

I am not even sure if OP can read my post way down here but will throw in my 2 cents. I hate Medicare wellness visits. Practically no one ever wants to come in for just the Medicare wellness and I do my best to tell them when they “cross the line” in the sense of triggering a copay. The actual wellness is limited but does have some benefit

I believe The code the OP got charged is a relatively new code regarding advanced care planning. Similar to tobacco cessation counseling it gives extra RVUs (money) to discuss these things, which I think is reasonable , as that can save a lot money down the road for patients and insurance. However, I have never thought to use it during a wellness(not that it’s wrong) but I could see how it could trigger a copay

The GERD aspect could have been put in the chart for completeness. Assement “managed by GI”. I suspect the doc had no idea this would trigger the copay

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

Post by Paulie » Fri Feb 08, 2019 8:39 am

AkwardDoct@rd wrote:
Fri Feb 08, 2019 12:50 am
I am not even sure if OP can read my post way down here but will throw in my 2 cents. I hate Medicare wellness visits. Practically no one ever wants to come in for just the Medicare wellness and I do my best to tell them when they “cross the line” in the sense of triggering a copay. The actual wellness is limited but does have some benefit

I believe The code the OP got charged is a relatively new code regarding advanced care planning. Similar to tobacco cessation counseling it gives extra RVUs (money) to discuss these things, which I think is reasonable , as that can save a lot money down the road for patients and insurance. However, I have never thought to use it during a wellness(not that it’s wrong) but I could see how it could trigger a copay

The GERD aspect could have been put in the chart for completeness. Assement “managed by GI”. I suspect the doc had no idea this would trigger the copay
I dont think the Doc wanted it to trigger a CoPay. There is a new billing person in the office and I feel she took it upon her self to code it as such as it was "mentioned" in the Doc remarks that he is constant putting in his lap top

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Re: Is General Practitioner [billing Medicare correctly?]

Post by international001 » Fri Feb 08, 2019 2:31 pm

toofache32 wrote:
Thu Feb 07, 2019 9:41 pm

Not at the rates paid by Medicare. I find it truly fascinating that MOST Medicare patient think they have GREAT insurance and have no idea how low the reimbursement is, and have no idea how this affects their healthcare. When I was a Medicare doctor, it was amazing how these patients would just plop their entitled rears in my chair and say "fix me." They actually expected premium service at a SEVERE discount. As a surgical specialist, Medicare fees are 25% of my fees on average. Which bogleheads here would be happy to work for a 75% pay cut?
Pretty much any doctor in the world would like to work for a 75% pay cut of an US doctor.

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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Fri Feb 08, 2019 2:59 pm

international001 wrote:
Fri Feb 08, 2019 2:31 pm
toofache32 wrote:
Thu Feb 07, 2019 9:41 pm

Not at the rates paid by Medicare. I find it truly fascinating that MOST Medicare patient think they have GREAT insurance and have no idea how low the reimbursement is, and have no idea how this affects their healthcare. When I was a Medicare doctor, it was amazing how these patients would just plop their entitled rears in my chair and say "fix me." They actually expected premium service at a SEVERE discount. As a surgical specialist, Medicare fees are 25% of my fees on average. Which bogleheads here would be happy to work for a 75% pay cut?
Pretty much any doctor in the world would like to work for a 75% pay cut of an US doctor.
A Medicare doctor?
Can you explain your math?

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Re: Is General Practitioner [billing Medicare correctly?]

Post by LadyGeek » Fri Feb 08, 2019 3:55 pm

Please stay on-topic, which is about billing Medicare.
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Thecallofduty
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Re: Is General Practitioner [billing Medicare correctly?]

Post by Thecallofduty » Fri Feb 08, 2019 4:04 pm

OP ,

Have you spoken your concern directly with the doctor. I feel that a good physician will listen to your concern and try to make things right or at least give you a through justification on the charges.

I doubt that doctor was going out of their way to find an extra way to add fees when you were already there for a specific reason (wellness exam).
-thecallofduty

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Re: Is General Practitioner [billing Medicare correctly?]

Post by toofache32 » Fri Feb 08, 2019 4:11 pm

Thecallofduty wrote:
Fri Feb 08, 2019 4:04 pm
OP ,

Have you spoken your concern directly with the doctor. I feel that a good physician will listen to your concern and try to make things right or at least give you a through justification on the charges.

I doubt that doctor was going out of their way to find an extra way to add fees when you were already there for a specific reason (wellness exam).
Does the doctor own the business? What makes you think the doctor has anything to do with this, or that he has the authority to make financial decisions? Most doctors are employees just like the front desk lady answering the phone.

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

Post by JPM » Fri Feb 08, 2019 4:27 pm

An annual wellness service does not include an exam or update of existing medical problems. Some doctors will extend the visit with more service for people with limited material resources with the understanding that those people can only realistically afford to come for the one free visit per year. This practice is technically medicare fraud as it is accepting the "wellness" fee under false pretenses and instead or in addition providing actual treatment services not covered by the "wellness" rubric.

For people with high deductible commercial insurance plans and limited material resources, the "annual preventive health visit" mandated to be free to the patient by the Obamacare rules, doctors will often similarly expand the visit beyond preventive services knowing that every other service is going to be out-of-pocket for patients who cannot realistically afford any testing or followup visits not included under the covered preventive services rubric.

To the best of my understanding, the annual medicare wellness service is supposed to include:
Vision test-usually the eye chart with the big E
Hearing test: Usually a "whisper test" where the doctor or assistant has you face the wall and whispers "chocolate cake" or something similar to see if you can accurately hear it
May ask about falls and perhaps of hazards in the home causing them
Mental status check: Usually a short memory test like asking the day, date, month, and year along with a simple calculation test like subtracting 7 from 100 and then again subtracting 7 from each result until reaching 65. Sometimes a longer 30 point test of cognitive function by the doctor's assistant.
A review and update of current medications
A review and update of what doctors you are currently seeing and maybe whether you are planning any surgery in the coming year
Check of weight and blood pressure

On the Welcome to Medicare service there is the addition of a free electrocardiogram and a free abdominal aortic ultrasound for men who have smoked 100 lifetime cigarettes. One time only.

That is all. No physical exam, no other testing, no review of the status of any current health issues. No treatment. No advice. The data is transmitted to medicare for its statistical purposes. The collection of this set of data is prescribed by medicare. This does not resemble the annual physical or preventive exam the nonmedicare population receives.

In our large health system, a machine reviewed the doctors visit note and can change the procedure coding, i.e. the charges, based on its programmed interpretation of what the proper charge should be for the documentation in the report. A professional coder reviewed the change recommended by the machine. It probably searched key words as in other search devices.

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dm200
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Re: Is General Practitioner [billing Medicare correctly?]

Post by dm200 » Fri Feb 08, 2019 4:35 pm

My Kaiser Medicare annual appointment consists primarily of my PCP reviewing my record and updating any errors or more recent information. She has never checked my vision or hearing. She does note that I am seeing Optometry/Ophthalmology as prescribed. She reviews vaccination/inoculations and does them or schedules any needed. She also reviews medications - what I am taking and what she thinks I should be taking. If I disagree, we discuss. :)

For one year (about 4 or 5 years ago), those on Medicare had to schedule an Medicare annual wellness appointment. While in the waiting room, I was given some things to review including a "secret" word or phrase. I was supposed to remember it (could not keep the paper or write it down). Then, during the exam, my PCP would ask me for the secret word or phrase. If you did not correctly remember it, I think that was some kind of warning of possible memory loss or dementia. I remembered it.

Then, the next year - it all changed back and there was no special Medicare annual exam -

On several occasions, she has had an ECG done at that time.

One time, she listened to my heart with a stethoscope.

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

Post by Thecallofduty » Fri Feb 08, 2019 6:07 pm

toofache32 wrote:
Fri Feb 08, 2019 4:11 pm
Thecallofduty wrote:
Fri Feb 08, 2019 4:04 pm
OP ,

Have you spoken your concern directly with the doctor. I feel that a good physician will listen to your concern and try to make things right or at least give you a through justification on the charges.

I doubt that doctor was going out of their way to find an extra way to add fees when you were already there for a specific reason (wellness exam).
Does the doctor own the business? What makes you think the doctor has anything to do with this, or that he has the authority to make financial decisions? Most doctors are employees just like the front desk lady answering the phone.

If the OP is upset over a charge they should able to ask the physician why it was charged during the wellness visit. To my understanding during these wellness exams you should
Not be billed just because you have a diagnosis of x y or Z especially if the patient stated the Gi doctor is managing that condition.

At the end of the day I believe this is a billing issue. My point is they should not hesitate to at least ask the physician if they are unhappy with the response from billing people.
-thecallofduty

Turbo29
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Re: Is General Practitioner [billing Medicare correctly?]

Post by Turbo29 » Fri Feb 08, 2019 6:15 pm

toofache32 wrote:
Thu Feb 07, 2019 9:41 pm
8foot7 wrote:
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


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.
Not at the rates paid by Medicare. I find it truly fascinating that MOST Medicare patient think they have GREAT insurance and have no idea how low the reimbursement is, and have no idea how this affects their healthcare. When I was a Medicare doctor, it was amazing how these patients would just plop their entitled rears in my chair and say "fix me." They actually expected premium service at a SEVERE discount. As a surgical specialist, Medicare fees are 25% of my fees on average. Which bogleheads here would be happy to work for a 75% pay cut?

As I am sure you know, the reimbursement is low even in commercial policies. Having an HDHP has been eye opening to me as it results in me seeing exactly what the provider is getting. I don't know how an office stays afloat on what they get--the rent, the utilities, the equipment, the receptionist, the medical assistants, the back office personnel, insurance, etc. i went to my dermatologist for a routine followup and was shocked to see that the negotiated rate (which I paid as I was below my deductible) was $55. My primary doctor likewise gets low reimbursements for visits. I don't blame them for billing for every little thing that they have done. It seems like sort of a "war" going on between the insurance companies and the medical providers.

I do understand what people are upset about here though. I went to my primary doctor on a follow up with his NP and was asked about how I was doing on a medication they had prescribed. I mentioned an issue and asked if it could be a side effect. I also mentioned that I was aware that it was not listed in the monograph as a side effect but I had heard of others taking the same medication experiencing it. He said no that it was not a side effect and then he said, "Let's not talk about it any more." I immediately knew that was the signal that if I pursued it it would generate another billing code. I was thankful for the heads up.

Had he not given me a heads up and just billed for the other issue I would have thought that they were pushing the envelope as I did ask about the issue in the context of side effects of the treatment for the issue I was originally there for.
Last edited by Turbo29 on Fri Feb 08, 2019 6:22 pm, edited 1 time in total.

Turbo29
Posts: 591
Joined: Tue May 01, 2018 7:12 am

Re: Is General Practitioner [billing Medicare correctly?]

Post by Turbo29 » Fri Feb 08, 2019 6:21 pm

dm200 wrote:
Fri Feb 08, 2019 4:35 pm
My Kaiser Medicare annual appointment consists primarily of my PCP reviewing my record and updating any errors or more recent information. She has never checked my vision or hearing. She does note that I am seeing Optometry/Ophthalmology as prescribed. She reviews vaccination/inoculations and does them or schedules any needed. She also reviews medications - what I am taking and what she thinks I should be taking. If I disagree, we discuss. :)

For one year (about 4 or 5 years ago), those on Medicare had to schedule an Medicare annual wellness appointment. While in the waiting room, I was given some things to review including a "secret" word or phrase. I was supposed to remember it (could not keep the paper or write it down). Then, during the exam, my PCP would ask me for the secret word or phrase. If you did not correctly remember it, I think that was some kind of warning of possible memory loss or dementia. I remembered it.

Then, the next year - it all changed back and there was no special Medicare annual exam -

On several occasions, she has had an ECG done at that time.

One time, she listened to my heart with a stethoscope.
My wellness visits (I am not yet on Medicare) are always by either the NP or PA on my Doctor's staff. Over the past several years, NPs and PAs have come and gone. No two visits with different providers are ever the same. One of the PAs seemed like it was almost theater, sort of smoke and mirrors to make it look like he was evaluating my health. On the other end of the scale, some of the other providers seemed to definitely ask good questions and evaluate important indicators of my health.

edudumb
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Re: Is General Practitioner Scamming Medicare

Post by edudumb » Fri Feb 08, 2019 6:32 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.(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
I didn't know that they could charge us for asking questions?

What a coincidence. I also just went to the PCP (first time in life) and did physical check. Actually I only meant to go in for some vaccines (covered by insurance).
They said since it was my first visit, they had to do a physical check (?!) and full blood test (?!). They asked a bunch of questions and kept pressing me if I had any questions (I really didn't have any questions, thank god). Now the bill came, and it was $170 for the physical check (all covered) and $260 for the blood work (looks like it'll be covered as well).

The thing is that I still haven't done the vaccines.

toofache32
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Re: Is General Practitioner Scamming Medicare

Post by toofache32 » Fri Feb 08, 2019 8:59 pm

edudumb wrote:
Fri Feb 08, 2019 6:32 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.(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
I didn't know that they could charge us for asking questions?
During a yearly History & Physical, this is what “History” refers to.
Last edited by toofache32 on Sun Feb 10, 2019 2:30 pm, edited 1 time in total.

Good Listener
Posts: 706
Joined: Wed Dec 30, 2015 5:24 pm

Re: Is General Practitioner [billing Medicare correctly?]

Post by Good Listener » Sun Feb 10, 2019 1:50 pm

Broken Man 1999 wrote:
Wed Feb 06, 2019 1:42 pm
Good Listener wrote:
Wed Feb 06, 2019 11:34 am
the doctor did OP afavor. The Medicare wellness visit is extremely limited and really does not involve any physical exam except blood pressure, so by adding a diagnostic code for the other symptom then Medicare covers that. Otherwise your doctor could not discuss anything. I have no idea what co-pays people are talking about unless it is the 20% for which most of us have a supplement. Medicare is exactly opposite of health plans in ages before Medicare ....preventive care and labs are covered prior to Medicare by law. Medicare covers no preventive care except for that very limited bunch of wellness questions.
Actually Medicare provides for many preventative care services, starting with Abdominal aortic aneurysm screening to Smoking and tobacco-use cessation counseling...

For a look at the extensive preventative care, consult your copy of Medicare and You, I have the paper edition, so I don't know about the page formatting for the online version, so page numbers are only good for the 2019 paper edition.

The extensive preventative services list starts on page 30, and goes to page 49.

Seriously, check it out.

Also consider the lengthy list of Medicare approved immunizations!

Broken Man 1999
You're correct. I should have clarified I was referring to the annual wellness visit or annual eye exam and such things....

Broken Man 1999
Posts: 3340
Joined: Wed Apr 08, 2015 11:31 am

Re: Is General Practitioner [billing Medicare correctly?]

Post by Broken Man 1999 » Sun Feb 10, 2019 2:24 pm

Good Listener wrote:
Sun Feb 10, 2019 1:50 pm
Broken Man 1999 wrote:
Wed Feb 06, 2019 1:42 pm
Good Listener wrote:
Wed Feb 06, 2019 11:34 am
the doctor did OP afavor. The Medicare wellness visit is extremely limited and really does not involve any physical exam except blood pressure, so by adding a diagnostic code for the other symptom then Medicare covers that. Otherwise your doctor could not discuss anything. I have no idea what co-pays people are talking about unless it is the 20% for which most of us have a supplement. Medicare is exactly opposite of health plans in ages before Medicare ....preventive care and labs are covered prior to Medicare by law. Medicare covers no preventive care except for that very limited bunch of wellness questions.
Actually Medicare provides for many preventative care services, starting with Abdominal aortic aneurysm screening to Smoking and tobacco-use cessation counseling...

For a look at the extensive preventative care, consult your copy of Medicare and You, I have the paper edition, so I don't know about the page formatting for the online version, so page numbers are only good for the 2019 paper edition.

The extensive preventative services list starts on page 30, and goes to page 49.

Seriously, check it out.

Also consider the lengthy list of Medicare approved immunizations!

Broken Man 1999
You're correct. I should have clarified I was referring to the annual wellness visit or annual eye exam and such things....
No problem. I go Wednesday for my AWV. I have no interest in saving my $5 co-pay by setting up another appointment to discuss other things. One and I'm done, unless the blood-work results demand a second visit. Usually he just calls me with good news or chides me about my A1C, not even that lately, as I've been pretty good about my diet.

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

IMO
Posts: 588
Joined: Fri May 05, 2017 6:01 pm

Re: Is General Practitioner Scamming Medicare

Post by IMO » Sun Feb 10, 2019 3:39 pm

chessknt wrote:
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.
OP: This is a good reply.

I'd add, it is very likely your GP (or any other health care provider) doesn't have the best understanding of billing and procedure codes. There are always professional education courses offered to attempt to help. There is mistaken underbilling, mistaken overbilling, and rarely there will be fraudulent billing. A chart note/electronic chart note can be audited by a private insurance company, medicare/medicaid. If a pattern is detected the health care provider can be held liable for overcharges (not the billing department who may have advised the provider what to "properly bill").

There can also be some variety in coding from the "coding specialists" on how to "properly" code the complexities to make matters worse. Even if a chart note is audited, one has to presume the auditor also is properly understanding the coding complexity....

If there are concerns about a bill, it is best to go and physically sit down and discuss with the billing department.

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