Challenging a physician's bill

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Topic Author
Godot
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Challenging a physician's bill

Post by Godot »

I am challenging a $525 physician bill and would appreciate any honest feedback about what you believe my chances are for having the charges waived.

Dr. X was my primary care provider in 2019, and his services were covered by my insurance provider. When I made the appointment to see him back in the spring this year, I gave my insurance information to his office who assured me that they accepted it. It's worth noting that he had moved to a new location since I had last seen him in 2019.

My so-called annual “physical” took all of 8 minutes, with the bulk of it consisting of Dr. X asking standard questions and typing into a computer. Dr. X did absolutely nothing apart from having me cough and pretending to look in my ear (half second swipe with his flashlight). I’m a 61-year old man. No DRE, no testing of reflexes, etc..

When I left, instead of handing me a prescription, Dr. X mistakenly handed me pages of medical history and prescription information for another patient! I discovered this mistake upon arriving home, and called his office immediately. Even that they screwed up, and CVS pharmacy had to call in more than once to get it fixed.

In addition, Dr. X said that he would have a ColoGuard colon cancer detection kit sent to me. That was six months ago. Still no kit.

Turns out that Dr. X in fact does not accept my insurance, and his medical group has billed me $525, which I have appealed, noting all of the information described above.

I'm appalled at a few things, including the fact that any PCP charges $525 for an eight-minute "physical"!

Handicap my chances of getting this bill waived, please.
Estragon: I can't go on like this. | Vladimir: That's what you think. | ― Samuel Beckett, Waiting for Godot
123
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Re: Challenging a physician's bill

Post by 123 »

You should be able to get the bill covered as an "out of netowrk" item for which your own insurance company should reimburse you. You will likely incur some out-of-pocket portion.
The closest helping hand is at the end of your own arm.
Bobby206
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Re: Challenging a physician's bill

Post by Bobby206 »

I think you are misguided focusing on stuff like "I'm appalled at a few things, including the fact that any PCP charges $525 for an eight-minute "physical"!" Likewise the fact that he made mistakes doesn't matter.

I would focus on them saying they accepted your insurance as that is the key to me. I can't imagine any, even medium level, professional that is going to fight about a $500 bill.

I would say 75% chance of success.

Good luck.
Savermom
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Re: Challenging a physician's bill

Post by Savermom »

I would also add that this is the price that they would bill your insurance, and if it was in network, your insurance would pay a lower negotiated rate.

I would politely call, explain that you were told that your insurance was accepted, otherwise you would have made an appointment with a different practice. I would say that I understand that the insurance usually pays you less than what they bill you. Is there anyway that you could please pay a more reasonable price- could they please look up the “cash price” (what people pay without insurance)?

If you are not given a reasonable price, ask to speak to the billing manager and be sure to state that you were told that your insurance was accepted and ask for a more affordable price
FarmWife
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Re: Challenging a physician's bill

Post by FarmWife »

You could offer to pay 10% over the medicare reimbursement rate (medicare pays crazy low, so maybe 20%). The doctor spent 8 min with you, but thousands of hours and dollars on his education and continuing education and insane insurance, so those 8 minutes are more valuable than you'd think.

Sites like healthcarebluebook.com are also available to help determine fair pricing for what you received.
Normchad
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Re: Challenging a physician's bill

Post by Normchad »

Your physician and their office sounds like a bunch of chuckleheads.

I agree you should call them up, explain to them what happened, that they told you they accepted your insurance when in fact they don't, and see what they say. You can submit your bill to your own insurance, and see what they say. I think mine would cover something like (80% of Reasonable and Customary) charges.

I'd try to get the doctor office to agree to whatever it is that your insurance will actually reimburse you.

And I'd never go back there......

My dentist is out of network. But I know it, and he knows it. But his office dutifully bills my insurance and gets what they can. Then they send me a bill for the rest.
gazelle1991
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Re: Challenging a physician's bill

Post by gazelle1991 »

Welcome to the nightmare that is the US healthcare system!

You may be able to contest your bill but be prepared to waste a lot of your time getting there. The easiest route is probably negotiate to pay the "cash price" since they don't accept your insurance.
Topic Author
Godot
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Re: Challenging a physician's bill

Post by Godot »

FarmWife wrote: Sun Sep 20, 2020 5:25 pm You could offer to pay 10% over the medicare reimbursement rate (medicare pays crazy low, so maybe 20%). The doctor spent 8 min with you, but thousands of hours and dollars on his education and continuing education and insane insurance, so those 8 minutes are more valuable than you'd think.

Sites like healthcarebluebook.com are also available to help determine fair pricing for what you received.
Thanks for the suggestion, FarmWife, though I certainly disagree with your comment about the value of the 8 minutes. He proved himself incompetent in every way.
Estragon: I can't go on like this. | Vladimir: That's what you think. | ― Samuel Beckett, Waiting for Godot
Topic Author
Godot
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Re: Challenging a physician's bill

Post by Godot »

Normchad wrote: Sun Sep 20, 2020 5:35 pm Your physician and their office sounds like a bunch of chuckleheads.

I agree you should call them up, explain to them what happened, that they told you they accepted your insurance when in fact they don't, and see what they say. You can submit your bill to your own insurance, and see what they say. I think mine would cover something like (80% of Reasonable and Customary) charges.

I'd try to get the doctor office to agree to whatever it is that your insurance will actually reimburse you.

And I'd never go back there......

My dentist is out of network. But I know it, and he knows it. But his office dutifully bills my insurance and gets what they can. Then they send me a bill for the rest.
Thx, Normchad. No plan on going back, though I do plan on posting a Yelp review after the issue is resolved.
Estragon: I can't go on like this. | Vladimir: That's what you think. | ― Samuel Beckett, Waiting for Godot
cricket49
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Re: Challenging a physician's bill

Post by cricket49 »

This happened to me when I was traveling and fell while hiking. Called the minor medical clinic and they stated my BCBS was accepted in network. I asked the receptionist again when providing my card if the facility was in network. She assured me it was.

Two months later I received an EOB from BCBS with the charges applied out of network (another high deductible). I called the minor clinic and got the run around even after speaking to the supervisor.

I disputed the charge with BCBS and explained how two people at the clinic gave me incorrect information. BCBS got involved and the clinic agreed to accept charges as in network per BCBS coding. I had already met my deductible and out of pocket maximum so BCBS paid the charges.
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AnEngineer
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Re: Challenging a physician's bill

Post by AnEngineer »

Does ACA requirement for free annual physical have an out of network exception?
toofache32
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Re: Challenging a physician's bill

Post by toofache32 »

What does this have to do with the doctor? You should be bringing this up with the business owner. Your doctor is just an employee....same as the nurse. Why aren't you bringing this up with the nurse? Fascinating how people still think the doctors are responsible for these billing/coding issues.

Bring it up with the business managers. The doctor doesn't know and doesn't care. When I fly on an airline and they lose my luggage, I don't complain to the pilot, I complain to the airline.
Topic Author
Godot
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Re: Challenging a physician's bill

Post by Godot »

toofache32 wrote: Sun Sep 20, 2020 8:14 pm What does this have to do with the doctor? You should be bringing this up with the business owner. Your doctor is just an employee....same as the nurse. Why aren't you bringing this up with the nurse? Fascinating how people still think the doctors are responsible for these billing/coding issues.

Bring it up with the business managers. The doctor doesn't know and doesn't care. When I fly on an airline and they lose my luggage, I don't complain to the pilot, I complain to the airline.
I sent a letter to the medical group (business owner) as well.
Estragon: I can't go on like this. | Vladimir: That's what you think. | ― Samuel Beckett, Waiting for Godot
sad2
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Re: Challenging a physician's bill

Post by sad2 »

I see a potential HIPAA violation here.

Hopefully they took actions to correct the improper sharing of PII and PHI.
OpenMinded1
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Re: Challenging a physician's bill

Post by OpenMinded1 »

sad2 wrote: Sun Sep 20, 2020 9:29 pm I see a potential HIPAA violation here.

Hopefully they took actions to correct the improper sharing of PII and PHI.
I was thinking the same thing. Surprised it took so long to be commented on in this thread.
sad2
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Re: Challenging a physician's bill

Post by sad2 »

OpenMinded1 wrote: Sun Sep 20, 2020 9:33 pm
sad2 wrote: Sun Sep 20, 2020 9:29 pm I see a potential HIPAA violation here.

Hopefully they took actions to correct the improper sharing of PII and PHI.
I was thinking the same thing. Surprised it took so long to be commented on in this thread.
Yeah. OP: This could be your leverage if you get no traction in negotiating a rate reduction.

HHS’ Office for Civil Rights has strong enforcement mechanisms and large penalties for violations of HIPAA.

https://www.hhs.gov/hipaa/for-professio ... index.html
Topic Author
Godot
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Re: Challenging a physician's bill

Post by Godot »

sad2 wrote: Sun Sep 20, 2020 9:29 pm I see a potential HIPAA violation here.

Hopefully they took actions to correct the improper sharing of PII and PHI.
Definitely a violation. And If they don't waive the charge I will be playing that card.
Estragon: I can't go on like this. | Vladimir: That's what you think. | ― Samuel Beckett, Waiting for Godot
rich126
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Re: Challenging a physician's bill

Post by rich126 »

I get yearly physicals and they all last longer than that. Generally the doctor requests blood work first. Then you come in for the physical exam and afterwards they sit down and discuss the exam and the blood results. And that has been with 3 drs in 2 states.
toofache32
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Re: Challenging a physician's bill

Post by toofache32 »

Godot wrote: Sun Sep 20, 2020 9:41 pm
sad2 wrote: Sun Sep 20, 2020 9:29 pm I see a potential HIPAA violation here.

Hopefully they took actions to correct the improper sharing of PII and PHI.
Definitely a violation. And If they don't waive the charge I will be playing that card.
Either way you're looking for a new doctor.
BogleFan510
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Re: Challenging a physician's bill

Post by BogleFan510 »

toofache32 wrote: Sun Sep 20, 2020 10:08 pm
Godot wrote: Sun Sep 20, 2020 9:41 pm
sad2 wrote: Sun Sep 20, 2020 9:29 pm I see a potential HIPAA violation here.

Hopefully they took actions to correct the improper sharing of PII and PHI.
Definitely a violation. And If they don't waive the charge I will be playing that card.
Either way you're looking for a new doctor.
Mental image of Elaine from Seinfeild searching for an MD who doesn't have the notes that she is 'difficult.'
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White Coat Investor
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Re: Challenging a physician's bill

Post by White Coat Investor »

Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course
000
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Re: Challenging a physician's bill

Post by 000 »

White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
Someone's got a nasty case of Tunnelis Visionitis over here!

Quick! Call a doctor!

Oh, wait...
FishTaco
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Re: Challenging a physician's bill

Post by FishTaco »

Might
EnjoyIt
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Re: Challenging a physician's bill

Post by EnjoyIt »

000 wrote: Mon Sep 21, 2020 12:19 am
White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
Someone's got a nasty case of Tunnelis Visionitis over here!

Quick! Call a doctor!

Oh, wait...
Please explain.
A time to EVALUATE your jitters: | https://www.bogleheads.org/forum/viewtopic.php?f=10&t=79939&start=400#p5275418
potatopancake
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Re: Challenging a physician's bill

Post by potatopancake »

Godot wrote: Sun Sep 20, 2020 3:54 pm I’m a 61-year old man. No DRE, no testing of reflexes, etc..
Did you want a DRE? That may be a first.
Cyanide123
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Re: Challenging a physician's bill

Post by Cyanide123 »

Godot wrote: Sun Sep 20, 2020 3:54 pm I am challenging a $525 physician bill and would appreciate any honest feedback about what you believe my chances are for having the charges waived.

Dr. X was my primary care provider in 2019, and his services were covered by my insurance provider. When I made the appointment to see him back in the spring this year, I gave my insurance information to his office who assured me that they accepted it. It's worth noting that he had moved to a new location since I had last seen him in 2019.

My so-called annual “physical” took all of 8 minutes, with the bulk of it consisting of Dr. X asking standard questions and typing into a computer. Dr. X did absolutely nothing apart from having me cough and pretending to look in my ear (half second swipe with his flashlight). I’m a 61-year old man. No DRE, no testing of reflexes, etc..

When I left, instead of handing me a prescription, Dr. X mistakenly handed me pages of medical history and prescription information for another patient! I discovered this mistake upon arriving home, and called his office immediately. Even that they screwed up, and CVS pharmacy had to call in more than once to get it fixed.

In addition, Dr. X said that he would have a ColoGuard colon cancer detection kit sent to me. That was six months ago. Still no kit.

Turns out that Dr. X in fact does not accept my insurance, and his medical group has billed me $525, which I have appealed, noting all of the information described above.

I'm appalled at a few things, including the fact that any PCP charges $525 for an eight-minute "physical"!

Handicap my chances of getting this bill waived, please.
The bill would be a lot less if you had insurance because of discounts that insurance companies have negotiated. Cash patients get the highest bills, most of them don't pay it, so the ones that do subsidize the cost of those patients that don't pay their bill.

The same $525 would likely have been $200 with insurance, and insurance picking up the full bill.

Also there is a lot of work on the backend that physicians do including reviewing meds, past medical history, previous notes, formulating plans and documenting the visit. Most of the time honestly a thorough exam only changes my plan maybe 5-10 percent of the times. 90-95 percent of the times, putting hands on the patient doesn't add much to the equation, at least that's true as an ER doctor. And most ER doctors will agree. I can't say if that's true for PCPs. But most of the time, an experienced physician will know what to do while knowing just your age, pmh, risk factors, chief complaint, and vitals. Most of those are easier to see in a medical record.

On a side note you should appeal with your insurance and the office. They might decrease the bill if you ask them. Also, physicians usually don't know much about billing. Almost always it's a third party doing our billing. We're just trying to do what we can with increasing volume pressures. A lot of pcps see 4 patients an hour. That means 15 minutes to review chart, see patient, make a plan, document a note, send any prescriptions etc.

Last night i had 7 people drop in 25 minutes when i was single coverage in my ER, how much time do you think i spent with each patient? I would love to just sit take my time.... It's not easy being a physician. Our admin over Lords keep trying to make an extra Buck by increasing volumes and decreasing staffing.

Also....a DRE is only a marginally useful exam. Even testing for PSA is a hotly debated topic. And who cares about reflexes??? I mean why? What valuable information is that really going to give me? Were you going in with back pain that your reflexes needed an evaluation? If not, then who cares about reflexes? That would be the exact same as the half second ear exam that will not give any valuable information.
quantAndHold
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Re: Challenging a physician's bill

Post by quantAndHold »

White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
The system is clearly broken. You’d think doctors, who clearly have a vested interest in the system working properly, would by working to fix it, instead of whining on an Internet forum every time a patient shares their bad experience with the system.

I don’t charge my customers up front, either. But my customers know how much things before the service is rendered. It sounds like the guy got billed $500 for his annual “well patient exam,” which is supposed to have a zero copay. I would be mighty upset to the point of finding ways to refuse to pay if that happened to me, too.
Yes, I’m really that pedantic.
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8foot7
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Re: Challenging a physician's bill

Post by 8foot7 »

White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
With respect, violating federal law by sharing another patient's information, not ordering a screening kit the patient requested, and mistakenly confirming accepted insurance is simply professional incompetence. I am not a doctor so can't comment on the value of the (seemingly non-existent) actual physical examination here, but this at least two of these three mistakes are on the doctor, and that shouldn't have anything to do with billing or payment.

To the OP, I would generously assume this doctor earns $500 an hour, so eight minutes of his time is worth $67. I would offer to pay that in full settlement of this appointment, disregarding the privacy violation and the lack of follow-up on your requested service as well as the time and expense of sorting out the billing office mistake regarding your insurance, and then find another doctor.
toofache32
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Re: Challenging a physician's bill

Post by toofache32 »

potatopancake wrote: Mon Sep 21, 2020 8:21 am
Godot wrote: Sun Sep 20, 2020 3:54 pm I’m a 61-year old man. No DRE, no testing of reflexes, etc..
Did you want a DRE? That may be a first.
I was thinking the same thing. As for the 8 minutes, I'm sure he could take longer next time if you ask.
toofache32
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Re: Challenging a physician's bill

Post by toofache32 »

White Coat Investor wrote: Sun Sep 20, 2020 11:57 pm Ahhh...the problems of being in an industry where you don't collect your payment up front or at the time of service. Now nobody is happy. Patient mad because he got a bill and lousy care. Doctor mad because he didn't get paid and forced to try to see patients in 8 minutes. And the insurance company is laughing all the way to the bank.

No wonder doctors are leaving medicine as soon as they can afford to.
Exactly why I collect up front. Patients love having no surprises and I never ask for more later.
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William Million
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Re: Challenging a physician's bill

Post by William Million »

I have trouble believing a serious physical would not include blood, urine, stool lab work,possibly chest x-ray, prostrate, blood pressure, etc, and that the doctor would discuss any health issues with the patient (family history, current issues, etc) after examining him and evaluating the lab results. Just 8 minutes without the lab work and more thorough physical examination seems like a waste of time to me.
stoptothink
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Re: Challenging a physician's bill

Post by stoptothink »

William Million wrote: Mon Sep 21, 2020 11:38 am I have trouble believing a serious physical would not include blood, urine, stool lab work,possibly chest x-ray, prostrate, blood pressure, etc, and that the doctor would discuss any health issues with the patient (family history, current issues, etc) after examining him and evaluating the lab results. Just 8 minutes without the lab work and more thorough physical examination seems like a waste of time to me.
It is pretty much a waste of time, but that is the extent of most annual physical exams. The last one I did took less than 8min and the physician was only there briefly to ask if I had any concerns and sign-off. At least mine was covered.
toofache32
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Re: Challenging a physician's bill

Post by toofache32 »

stoptothink wrote: Mon Sep 21, 2020 11:47 am
William Million wrote: Mon Sep 21, 2020 11:38 am I have trouble believing a serious physical would not include blood, urine, stool lab work,possibly chest x-ray, prostrate, blood pressure, etc, and that the doctor would discuss any health issues with the patient (family history, current issues, etc) after examining him and evaluating the lab results. Just 8 minutes without the lab work and more thorough physical examination seems like a waste of time to me.
It is pretty much a waste of time, but that is the extent of most annual physical exams. The last one I did took less than 8min and the physician was only there briefly to ask if I had any concerns and sign-off. At least mine was covered.
This can be done by nurses. I don't know why physicians do these.
njuser
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Re: Challenging a physician's bill

Post by njuser »

quantAndHold wrote: Mon Sep 21, 2020 10:01 am The system is clearly broken. You’d think doctors, who clearly have a vested interest in the system working properly, would by working to fix it, instead of whining on an Internet forum every time a patient shares their bad experience with the system.

I don’t charge my customers up front, either. But my customers know how much things before the service is rendered. It sounds like the guy got billed $500 for his annual “well patient exam,” which is supposed to have a zero copay. I would be mighty upset to the point of finding ways to refuse to pay if that happened to me, too.
How would you like the doctors to fix it? In my plan, it is clearly spelled out that if I go out of network, my plan pays nothing for well care. Everyone gets a summary of benefits from their plan each year that should spell out everything their plan does and does not cover.

The patient and the insurance company have an agreement. In the end, it is up to the patient to follow his insurance companies rules for reimbursement. Ideally, the patient should have checked online or by phone with his insurance company to confirm the doctor being in network. There are thousands of plans and your doctor isn't familiar with every one. In the end, unfortunately, it is up to the patient to make sure he knows his coverage. Read the rules of your plan.

That being said, the doctor will probably negotiate with the patient because most of them are understanding people. Try getting some sympathy from your insurance company.
njuser
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Re: Challenging a physician's bill

Post by njuser »

123 wrote: Sun Sep 20, 2020 4:17 pm You should be able to get the bill covered as an "out of netowrk" item for which your own insurance company should reimburse you. You will likely incur some out-of-pocket portion.
If his plan has OON coverage. My plan does not cover anything OON unless it is an emergency.
hnd
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Re: Challenging a physician's bill

Post by hnd »

when my wife had our first child she got an epidural which of course was not covered by insurance.

we got a bill for 800 bucks. dr came in was there for 10 minutes boom 800 bucks. whatever.

I called them and basically told them theyd be getting a 20 dollar check from me for the next 40 months. If you send it to collections they'll get a 20 dollar check until its paid off. OR i can bring a check today for 250 dollars. I spoke to the business manager of the office. not some secretary.

I got a call later that day asking to bring the check in the morning.
stoptothink
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Re: Challenging a physician's bill

Post by stoptothink »

hnd wrote: Mon Sep 21, 2020 1:34 pm when my wife had our first child she got an epidural which of course was not covered by insurance.

we got a bill for 800 bucks. dr came in was there for 10 minutes boom 800 bucks. whatever.

I called them and basically told them theyd be getting a 20 dollar check from me for the next 40 months. If you send it to collections they'll get a 20 dollar check until its paid off. OR i can bring a check today for 250 dollars. I spoke to the business manager of the office. not some secretary.

I got a call later that day asking to bring the check in the morning.
When my son was born, my wife got the epidural and then literally 2 mins later my son popped out. Entire labor process was <30min. But, my wife Ok'd the epidural so I wrote the check (I think ours was like $1100). The process is screwed up, but at least I wasn't paying for something I didn't know about or we didn't receive.

Now, I have a real nightmare involving <45min in a hospital for tubes for my son's ears, that we were initially billed $12.5k for and ended up paying ~$8500 for out of pocket.
Last edited by stoptothink on Mon Sep 21, 2020 1:44 pm, edited 1 time in total.
Seasonal
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Re: Challenging a physician's bill

Post by Seasonal »

William Million wrote: Mon Sep 21, 2020 11:38 am I have trouble believing a serious physical would not include blood, urine, stool lab work,possibly chest x-ray, prostrate, blood pressure, etc, and that the doctor would discuss any health issues with the patient (family history, current issues, etc) after examining him and evaluating the lab results. Just 8 minutes without the lab work and more thorough physical examination seems like a waste of time to me.
The US Preventative Services Task Force lists procedures supported by science for an annual physical. Some of the things you list are included, some are not.

The ACA provides that insurance is generally required to cover things rated A or B. https://www.uspreventiveservicestaskfor ... mendations Other parts of the site link to studies listing other procedures and explaining why those are rated lower.

Given forum rules, let's not discuss the pros and cons of medical procedures.
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FIREchief
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Re: Challenging a physician's bill

Post by FIREchief »

What does it mean for a provider to tell you that they "accept your insurance?" It may mean nothing more than that they will see you on the hopes of ultimately being paid by someone. When is comes to private insurance, in close to 100% of the cases the terms "in network," "out of network" and "covered expense" are key. I would never just ask the person at the front desk to confirm my insurance coverage.

The responsibility is on the patient to do their homework:

a) Confirm with their insurance company that the provider is either in network or will be covered as out of network (typically at higher cost to the patient). Either of these will ensure that a lower contracted rate or "reasonable rate" will be charged and covered at some level. If neither of these apply, than the patient will likely be billed exorbitant retail pricing as has occurred with the OP. HMOs typically do NOT have any out of network coverage other than for emergencies. I believe that PPO plans typically do have some level of out of network coverage at higher costs to the patient.

b) Confirm with their insurance company that the procedure is a covered expense. This can be either very simple or complicated beyond comprehension. At times, the best clue I've found is to determine if it is covered by Medicare (even though I'm on private coverage prior to age 65). If Medicare considers it an eligible expense, many times private insurance will mimic that. If it's not a covered expense, insurance will do nothing and, again, the patient will be at the total mercy of the provider.

This is all based solely on my experience, which may be different than what others have experienced. Please share. 8-)
I am not a lawyer, accountant or financial advisor. Any advice or suggestions that I may provide shall be considered for entertainment purposes only.
babyboglehead
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Joined: Thu Apr 11, 2019 11:15 am

Re: Challenging a physician's bill

Post by babyboglehead »

It sounds like there are a number of main issues with your experience:
1) You were told your insurance was accepted as in-network by this provider's office, and it clearly was not.
2) You feel your bill is too high relative to the services performed.
3) Giving you someone else's medical information was a blatant HIPAA violation. They need to fix whatever process landed those in your lap.
4) You were told a cologuard kit would be sent to you, and it was not sent.
5) You received what you perceive as insufficient medical services overall.

I separate these all because both the issues and the remedies likely fall to different people.
1) This would fall to the administrative staff. Different titles at different practices, but typically someone like an office manager would handle this. The MD would be the person with the least knowledge and time to address this.

2) Either the office or insurance should have provided a line-item summary of the services for which you are being billed. The physician fee is one of those, but a lot of the other questions and screening done by the nurse/MA/LPN are separately billable. Things like vision exams, hearing screens, depression screens, etc. have their own billings codes. Whether any of these justifies the charges is beside the point. Unless you are on some health plan that was grandfathered in, the ACA requires all insurers to cover these types of preventative services, including the physician's fee, with no cost sharing, so you personally should have been charged $0 if not for the error in #1. Now, with Medicare there is a lot of (ludicrous) nuance to this, and as a pediatrician I frankly don't know the ins and outs of it, but if you are on medicare and the visit was billed (depending on the practice might be the MD who places the charge or might be a biller/coder) as an "Annual Physical" rather than a "Medicare Wellness Visit" that might be the coverage issue. The following links might be helpful:
https://khn.org/news/medicare-covers-we ... -physical/
https://www.cms.gov/Outreach-and-Educat ... xtOnly.pdf

For what it's worth, if you physician is employed and on a productivity-based contract, only about $80-120 of this is actually going to him personally.

3) This should not have happened, period. If the MD personally handed these files to you, they are at fault.

4) There are a million reasons this might happen. Calling to ask the medical staff (nurse/MA/LPN) if the order was placed at all would be best the place to start. If it was they would be the most helpful in hunting down where in the supply chain the issue happened so you can get your test. If it wasn't they can harass the MD on your behalf. Typically this would involve them entering a patient-related message in the electronic health record that the MD wouldn't close without submitting the order.

5) You are getting bad medical information from other people in this forum. More testing does not equal better medical care. For every story of the asymptomatic patient whose x-ray after a car crash serendipitously finds their early-stage bone cancer, there are 20 more of people who either were offered or pushed for and received unnecessary medical tests or imaging that uncovered incidental findings of unclear significance that then resulted in more unnecessary testing, surgeries, medication, etc, often resulting in direct harm to the patient (e.g. 77 year old goes for biopsy of incidentally found lung mass, gets pneumonia after anesthesia, dies). If you have symptoms or concerns it's a different ball game, but the amount of testing actually recommended for people of all ages is actually less that what a lot of people expect and often less than what many practices do. In general, practices don't get paid for labs that are collected and processed elsewhere, but are reimbursed for labs done in-office, such as fingerstick hemoglobin, fingerstick glucose, urine dips, EKGs, x-rays, if they have a machine in-house, etc. For this reason a lot of practices tend to do more of these than current guidelines actually recommend. This is bad medical care. Again, I'm not an adult doctor but a concise spread of recommended screening can be found here:
https://my.clevelandclinic.org/ccf/medi ... elines.pdf

If it's there and wasn't done, it should have been. If it's not there and wasn't done, great.
Not your main question, but as an aside I can tell you that when you look into 250 working days x 14 patients/day x 2 ears per patient = 7,000 ears a year give or take, it only takes about a quarter of a second to get a solid picture, which is great because as a pediatrician it's about all I can ever hope to get.
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FIREchief
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Re: Challenging a physician's bill

Post by FIREchief »

Godot wrote: Sun Sep 20, 2020 3:54 pm I'm appalled at a few things, including the fact that any PCP charges $525 for an eight-minute "physical"!
The money my PCP receives for my 8 minute physical also pays her for 12 months of coverage for phone calls, portal messaging, prescription refills, test result interpretation/feedback, office/staff overhead, her 23 years of expensive education, etc. (I just made up the 23 years as I have no idea....)
I am not a lawyer, accountant or financial advisor. Any advice or suggestions that I may provide shall be considered for entertainment purposes only.
Helo80
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Re: Challenging a physician's bill

Post by Helo80 »

Godot wrote: Sun Sep 20, 2020 3:54 pm I am challenging a $525 physician bill and would appreciate any honest feedback about what you believe my chances are for having the charges waived.
BLUF - Pay the Bill and do not complain. Doctors are expensive.

https://www.whitecoatinvestor.com/bogleheads/

# 9 Doctor Bills Should Always Be Negotiated Retroactively

The last couple of years an “anti-doctor” vibe seems to have crept onto the forum. Post after post in the “consumer issues” section seems to relate to a medical bill and how unfair it is. While I’ll be the first to admit that our health care system (and especially how we pay for it) has serious problems, the repeated suggestions on the forum to not pay bills or demand discounts wear thin. Guess what? Doctors are expensive. If the bill is accurate and your insurance company has paid its portion, then it’s time for you to pay your portion. If you don’t like the deal you made with your insurance company or the deal the insurance company made with the doctor on your behalf, then go to a new insurance company. But singling out physician bills over all other professions is not fair when they have already provided you the promised services. - WhiteCoatInvestor

Credit to WCI for his answer to your question.
Seasonal
Posts: 2155
Joined: Sun May 21, 2017 1:49 pm

Re: Challenging a physician's bill

Post by Seasonal »

Helo80 wrote: Mon Sep 21, 2020 2:13 pm
Godot wrote: Sun Sep 20, 2020 3:54 pm I am challenging a $525 physician bill and would appreciate any honest feedback about what you believe my chances are for having the charges waived.
BLUF - Pay the Bill and do not complain. Doctors are expensive.

https://www.whitecoatinvestor.com/bogleheads/

# 9 Doctor Bills Should Always Be Negotiated Retroactively

The last couple of years an “anti-doctor” vibe seems to have crept onto the forum. Post after post in the “consumer issues” section seems to relate to a medical bill and how unfair it is. While I’ll be the first to admit that our health care system (and especially how we pay for it) has serious problems, the repeated suggestions on the forum to not pay bills or demand discounts wear thin. Guess what? Doctors are expensive. If the bill is accurate and your insurance company has paid its portion, then it’s time for you to pay your portion. If you don’t like the deal you made with your insurance company or the deal the insurance company made with the doctor on your behalf, then go to a new insurance company. But singling out physician bills over all other professions is not fair when they have already provided you the promised services. - WhiteCoatInvestor

Credit to WCI for his answer to your question.
Interesting answer that does not deal with OP's facts.
marcopolo
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Re: Challenging a physician's bill

Post by marcopolo »

Cyanide123 wrote: Mon Sep 21, 2020 8:37 am
The bill would be a lot less if you had insurance because of discounts that insurance companies have negotiated. Cash patients get the highest bills, most of them don't pay it, so the ones that do subsidize the cost of those patients that don't pay their bill.

The same $525 would likely have been $200 with insurance, and insurance picking up the full bill.
I agree with many that have said it is the responsibility of the patient to check with their own insurance plan and rules to make sure their provider and procedure are covered.

Having said that, I am honestly curious if you, or any of the other medical professionals here, know the rationale/history of why the original bills are what seem like completely unreasonable numbers? Here is an example i posted a while back:

My wife recently had a Dexa scan done at a local hospital. The hospital charge was for $1468. They accepted $38 from the insurance company. I assume this was the negotiated rate. Other insurance companies probably have similar negotiated rates for this procedure. This must be profitable for the hospital at this rate. So, what is the point of charging $1468 for a procedure that costs less than $38? Who would be expected to pay that rate?

This seems pretty common when i look at other EoBs from insurance provider, the original bill is often 10x or more than the negotiated rate. Many people post here saying that if you are paying cash (self pay), you will also get a significant discount (i have no experience with that). So what is the point of billing such a high amount? Is it just to catch the small fraction of people that are in the unfortunate situation of not having insurance, and will simply pay the bill without questioning it?
Once in a while you get shown the light, in the strangest of places if you look at it right.
Helo80
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Re: Challenging a physician's bill

Post by Helo80 »

Seasonal wrote: Mon Sep 21, 2020 2:17 pm Interesting answer that does not deal with OP's facts.

Every medical provider I have seen requires consent that charges not covered by insurance are to be covered by the patient.
Seasonal
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Re: Challenging a physician's bill

Post by Seasonal »

Helo80 wrote: Mon Sep 21, 2020 2:22 pm
Seasonal wrote: Mon Sep 21, 2020 2:17 pm Interesting answer that does not deal with OP's facts.
Every medical provider I have seen requires consent that charges not covered by insurance are to be covered by the patient.
That's not my experience. On rare occasion, the provider will ask for a specific consent to a specific procedure.

In any event, OP's complaint includes that the provider's office specifically said the doctor's services were covered by OP's insurance provider, plus a few other problems. The provider should take responsibility for the office's actions.
Seasonal
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Re: Challenging a physician's bill

Post by Seasonal »

marcopolo wrote: Mon Sep 21, 2020 2:19 pmThis seems pretty common when i look at other EoBs from insurance provider, the original bill is often 10x or more than the negotiated rate. Many people post here saying that if you are paying cash (self pay), you will also get a significant discount (i have no experience with that). So what is the point of billing such a high amount? Is it just to catch the small fraction of people that are in the unfortunate situation of not having insurance, and will simply pay the bill without questioning it?
Different insurance companies will negotiate different rates. Some people will pay the listed rate. Many people feel better if given a substantial discount.
lstone19
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Re: Challenging a physician's bill

Post by lstone19 »

marcopolo wrote: Mon Sep 21, 2020 2:19 pm I agree with many that have said it is the responsibility of the patient to check with their own insurance plan and rules to make sure their provider and procedure are covered.
And to take it a step further, make sure they're in-network for YOUR plan, not just some plans of that insurance company. My wife has had an ongoing issue with one of her doctors. The doctor's office kept insisting he was in-network with Aetna but Aetna was processing them as out-of-network (makes no difference until we hit the HDHP in-network deductible but that will probably happen this year). Finally found out from Aetna that the doctor was in some Aetna plans but not ours.

Almost five years ago, my wife had an MRI at a place she had used before. Verified with them (but not insurance) that they were still in-network. Oops, they had apparently just dropped - so recently that billing office didn't know and still applied insurance rate (rather than full rate) but insurance paid $0 rather than 95% so significant difference. Wife called, told "yes, we're in-network" (so even the actual location office didn't know) and "don't worry about it". Sent bill back with WTF letter. Location closed shortly after that and we never heard from them further. Still saving notes just in case as it's potentially a mid four-figure amount. Yes, US health-care is royally messed up.
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Godot
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Re: Challenging a physician's bill

Post by Godot »

Helo80 wrote: Mon Sep 21, 2020 2:13 pm
Godot wrote: Sun Sep 20, 2020 3:54 pm I am challenging a $525 physician bill and would appreciate any honest feedback about what you believe my chances are for having the charges waived.
BLUF - Pay the Bill and do not complain. Doctors are expensive.

https://www.whitecoatinvestor.com/bogleheads/

# 9 Doctor Bills Should Always Be Negotiated Retroactively

Guess what? Doctors are expensive. If the bill is accurate and your insurance company has paid its portion, then it’s time for you to pay your portion. If you don’t like the deal you made with your insurance company or the deal the insurance company made with the doctor on your behalf, then go to a new insurance company.[/b][/u] But singling out physician bills over all other professions is not fair when they have already provided you the promised services. - WhiteCoatInvestor

Credit to WCI for his answer to your question.
You're kidding, right? Read my post: The physician did not in fact provide the "promised services." In fact, his services epitomized incompetence. That you believe anyone can simply "go to a new insurance company" suggests you have little, if any, experience with the U.S. healthcare system. I "singled out" the physician's bill because that is the source of my bad experience. I didn't think back on my experiences with "all other professions" and then settle on the medical profession to post about because I knew it would irk some bogleheads like yourself. Your smug response illustrates the elitist attitude at the core of a rotten healthcare system.
Estragon: I can't go on like this. | Vladimir: That's what you think. | ― Samuel Beckett, Waiting for Godot
Seasonal
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Joined: Sun May 21, 2017 1:49 pm

Re: Challenging a physician's bill

Post by Seasonal »

The doctors' offices I've dealt with over the past number of years have asked for insurance information when I first call, then appear to do an online check with the insurance company. Is this uncommon?
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