Written by Brandon Betancourt
I got a call from a mom recently. She wanted to know why she was being charged for both a preventive wellness visit and an office visit on the same date of service.
For those that don’t know, most visits to a pediatrician’s office are either considered an office visit, which generally include visits where the patient is sick, and wellness visits – which are those visits where the doc does a more comprehensive head to toe assessment of the child otherwise know as a physical.
This particular patient came in for a wellness visit, but the doctor also documented and addressed a heart condition that the patient has. The heart condition assessment triggered an office visit in addition to a yearly physical. In other words, our office submitted a claim to the patient’s insurance stating that both an office visit and a physical occurred during the encounter.
Mom wanted to know why the two charges since she was under the impression that checking a patient’s heart should be part of the physical.
I understood where the mom was coming from. Medical billing is very complicated and in many instances doesn’t make any sense. Not because the doctor or her office makes it complicated, but because the insurance companies designed it that way.
Here is how I explained it to her.
When you go to a restaurant, and order a dish, generally the meal will come with side foods. So, let’s say one is ordering a pasta primavera. The expectation is that in addition to the pasta, the dish is going to come with vegetables, which are included in the price of the dish.
Let’s say one decides to add chicken to the pasta primavera and the server says, “sure, but that will be extra.” Meaning, she will have to charge extra for the added chicken. When asked what you’ll like to drink, 9 out of 10 times, beverages will also be extra. And so will appetizers.
Healthcare is like an a la carte restaurant where some things are included in the price of the visit, but others are not.
But here is where it get a little complicated. Unlike the the restaurant, patients don’t pay for their bills directly to the doctor; insurance companies pay the doctor. And insurance companies, in an effort to provide more shareholder value, prefer to pay for the least amount of claims possible because the less they have to pay, the more money they make.
Thus, they require physicians to document everything that happened during the visit so they can determine how much they have to pay based on the policy purchased by the patient. In other words, they won’t take the doctor’s word for it. They want to see and review everything that was discussed during the visit with the patient so they can decide what should and should not get paid.
During this particular patient visit, I explained to the parent, in addition to the wellness visit, the doctor also assessed the child’s medical condition, which required the doctor to prescribe medication, order x-rays and a consult with a specialist.
Just like the appetizers and the added chicken is billed as “extra” at a restaurant, the assessment on the child’s condition was extra work for the doctor that is not included with the wellness visit payment.
And in her documentation, the doctor described to the the insurance company that the patient had required an “appetizer” and “chicken,” thus they should pay her more.
Essentially, the doctor was simply documenting the visit with everything she did in order to demonstrate to the insurance company what was done. And the heart condition assessment documented by the doctor triggered an office visit.
The parent appreciated the analogy and said that it was perfectly reasonable explanation. I was happy. I was able to communicate without insurance jargon and was understood. In my world, this is considered a good day.
Brandon is a practice administrator, speaker and blogger. He blogs regularly at PediatricInc.com