Paying for your restaurant bill and your doctor’s bill is not that different

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

Crossing State Lines: Crossing the Line?

In the search for reducing healthcare costs, some public policymakers have suggested allowing consumers to purchase health insurance across state lines. Theoretically, this would allow families to shop around for the best insurance deal, even if they aren’t a resident of the state in which the insurance is sold or regulated.

In general, increased access to choices drives down prices and increases competition; given the proliferation of online shopping for all kinds of other products, you might indeed find a great deal in another state. Even some state-based financial products, like 529 college savings plans, are marketed across state lines, allowing flexibility and consumer choice.

However, I’m opposed to selling health insurance plans across state lines: out-of-state insurance plans (including ERISA plans) can thumb their noses at a state’s consumer protection laws.

Here’s an example: Tennessee mandates that newborns be covered from the moment of birth to 30 days of age without any special action required on the part of the baby’s family (TCA 56-7-2301.) This is a good idea: moms shouldn’t have to call their insurance company’s 800 number in between contractions to ensure her baby gets added to her policy. The thirty-day rule gives families a short grace period to get their paperwork in order.

However, Tennessee law doesn’t apply to all infants born in Tennessee. Families who are employed by a big-box corporation headquartered in another state often have an insurance plan domiciled in that state. If mom and dad have, say, Blue Cross Blue Shield of Alabama — the company does not have to follow the 30-day rule of newborn care. They’re shocked to find out after their child is born (and too late to make other arrangements) that they owe hundreds or thousands of dollars to doctors and hospitals. It’s even more depressing when you realize these costs are incurred during a period when moms are taking time off work and family incomes are tight as a result.

Tennessee law also requires insurance companies to be transparent in their dealings with doctors: to pay clean claims promptly (56-32-126); to credential doctors fairly (56-7-1001), and to be up front about what doctors will be paid for their services ahead of time (56-7-1013). These laws protect employers, patients, and doctors from unfair insurance company tactics – but again, only as long as the company is an in-state company.

Our practice already spends a lot of resources policing our own state’s insurance companies. If they violate regulations, we can appeal to our state’s Department of Commerce and Insurance, our state’s legislature, and our state’s judiciary, all of whom are accountable to voters for their actions. Yet insurance companies in other states can blissfully ignore directives from our state, even though they’re insuring our state’s citizens. At last count, there were over 1300 out-of-state insurers during business in Tennessee; until consumer protections are more consistent, we need less of this, not more.


What I Wish Parents Knew About Medical Billing

Written by Brandon Betancourt

One of the things that I do a lot here at our practice is talk to parents about their health insurance coverage. The conversation is usually about why they have a balance on their child’s account.

Health insurance is very complicated. At our practice, we deal with health insurance all the time and even for us, it gets to be very complicated sometimes.

Today, I had a conversation with a patient’s parent regarding medical billing issues. After explaining some in-and-outs about why we do certain things, the parent mentioned she had no idea things were the way they were and now understands why doctors’ offices have to do what they have to do.

She also mentioned that we should do something to spread the word. She said, “I think it is important for other parents to know this. Otherwise, how are things going to get better?”

I thought her idea to spread the word was very good. Therefore, I decided to summarize our conversation in an effort to help other parents understand, at the very least, a portion of medical health insurance.

Coding — a lot of what doctors do

At a restaurant, generally you’ll get an itemized check that shows all the things you’ve ordered. Doctors do the same thing, but they do it in the medical chart.

Virtually every doctor who accepts health insurance uses codes (called CPT codes) that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these things are “coded” separately.

Why do docs do it this way?

These codes are used by the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. In other words, the health insurance company (the one actually paying for the services) wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does has a code.

For example, if you are coming in for a child’s well visit, the pediatrician will submit a “claim” to the insurance company using the following codes:

  • Established Well Visit – 99392
  • Developmental Testing – 96110
  • Hemoglobin – 85018
  • Finger/heel/ear stick – 36416
  • Lead Testing -83655
  • Hearing Screen – 92587

If the child gets immunizations, those have codes too.

  • DTAP-IPV – 90696
  • Flu – 90660

Vaccine administration also uses a distinct set of codes. To further complicate things, some vaccines have a single administration code used with them, and others have multiple administration codes for a single vaccine.

  • Admin – 90460
  • Admin – 90461
Oh, by the way…

Let’s say while you are in the examining room, you ask the doctor, “Ya know doc, little Lisa here has been pulling on her ear lately… she may have an ear infection. Can you check that for me really quick?”

This question requires the doc to perform an entirely different assessment than the well visit the child was getting.

The doctor, in order to show the insurance company that she did a completely different assessment, codes the ear pain diagnosis and adds a 99213 – which is an evaluation and management code that documents in the chart and on the claim to the insurance company that the doctor also checked the patient’s ear.

But we feel like we are being squeezed for every penny

Parents often think when they are looking at the bill that the doctor is nickel-and-diming parents, when in reality, it is the insurance company that requires the doc to show their work in this matter.

The health insurance company doesn’t accept the doctor telling them, “I did a well visit — pay me our agreed-upon fee.” They want to know all the things the doctor did during a patient’s visit so they can decide how much they ought to pay the doctor for his/her services.

Since most patients (or in the pediatrician’s case, parents) don’t pay the doctors directly, but rather the health insurance company, they want to know what took place during the visit so they know how much they ought to pay the doctor.

It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra.

Health care services are a la carte as well. 

Why then do patients have balances if insurance ought to have paid?

The insurance policy that a patient has chosen may not pay for all the services the doctor performed. So when the doc’s billing staff submits a claim for a visit, the health insurance company often comes back and says, “We are not responsible for these codes/services; these are the member’s responsibility per the member’s health insurance policy. ”

For example, the health insurance company may say, the policy your patient chose pays for a vision screen, but not for a hearing screen. Or they may say, we cover the well visit code, but not the ear ache code at the same time as the wellness visit.

Doctors get stuck with the bill

The doctor, already having performed services, now has to go to the patient and say, “Hey, remember that school physical I performed and you asked me about little Lisa’s earache? Well, your insurance says that the policy you have doesn’t cover the earache part, so I’d like to be paid for the work I perform in assessing your child’s earache.”

Of course, doctors don’t actually say that, but when a parent gets a bill for the earache, that is in essence what the doc is trying to say to the parent. And if one looks carefully at the  explanation of benefits (that document that the insurance company sends after they process a patient’s claim) one will notice they give an explanation as to why they are not going to pay the doctor for the service.

Funny how things work

Here is an interesting, but crazy fact. In many cases, had the doctor deferred the earache question and told the mom to make another appointment to address that issue during another appointment, the health insurance company would have most likely paid for the office visit.

However, had the doctor done that, the patient would have most likely gotten upset at the doctor.

By treating the earache question during the wellness visit, the doctor runs the risk of not being paid despite doing the work. On the other hand, not addressing the ear ache, the doc runs the risk of upsetting the parent, who will probably think the doc is trying to squeeze another $30 copayment, which is clearly not the case.

Cutting cost — not always a good idea

One of the major problems with this is that patients don’t understand what they are financially responsible for. Or, it’s often the case where patients don’t understand what type of health insurance they’ve purchased.

Just like with anything else, you get what you pay for. But patients overlook this issue when purchasing health insurance. They usually look at the monthly premiums and choose the lowest one. But by doing that, they are often reducing the amount of coverage, which means patients will get stuck with larger portions of their medical bills.

Growing trend to save cost

The health insurance company, in an effort to keep their premiums low, have shifted the cost to customers and their doctors. While in the past health insurance companies may have covered 100%, now they are reducing the monthly premiums but only covering 70% of one’s medical expense. Hence allthe high deductible plans out there.

Why wasn’t I told they insurance doesn’t cover?

In our practice – which is a small three-provider practice – we see on average 60 to 75 patients daily.

Add to that there are virtually thousands and thousands of different health plans. In fact, we have patients whose parents work for the same company, but because they are at different pay grades, have different insurance plans.

The answer is, we don’t have enough manpower or time to sit on the phone verifying every single patient’s healthcare coverage. I know of practices that do, and God bless them. But as a practice we believe it is the patient’s responsibility to find out what is covered and what is not covered. The more time we spend on the phone with a patient’s insurance company, the less time we are able to spend providing health care for our patients.


As a practice, we consider that treating patients based on what the insurance covers and what it doesn’t, instead of treating by what the patient actually needs, is an unethical way to practice medicine.

Although most doctors that I know will take into consideration health insurance stipulations, they will not compromise a child’s health as a result of health insurance restriction and cheap health insurance coverage plans.

I hope this post will give all that read it some insight and perspective on medical billing. If you have a question, or don’t understand why doctors’ office do medical billing, feel free to leave a comment and we will try to address it.

Oh, and thanks for reading…

Brandon Betancourt is a practice administrator for Salud Pediatrics. You can follow him on Twitter  @pediatricinc

What Can Your Pediatrician do for You—and What Can S/he NOT Do?

By Jesse Hackell, MD

When I made the decision to become a doctor, there was no question in my mind from the start that I would be a pediatrician. Why? Well, I liked children, even back then, just barely out of my own childhood. I also liked the pediatrician who had cared for me as I grew up—he wore sandals and love beads, which made him seem relevant to me, coming of age in the 60’s. (Thanks, Dr. Johnny!)

We all have our reasons for entering this challenging and ultimately rewarding and fulfilling field. But I think it is safe to say that at least one reason which we all share is that we truly want to provide care to children as they grow from infancy through childhood, and through adolescence into adulthood. We like children, and we want to see them grow up healthy and happy. So the broad answer to the question in the title about what can your pediatrician do for you is: We can do our best to help keep your children healthy as they grow, and help you to respond to the myriad challenges along the way.

But I really want to address the more mundane issues about what we can and cannot do for you.

We CAN provide you, as parents, with information and education about the choices you have when it comes to making decisions about your children. These decisions come even before your baby is born — from hospital care, circumcision for a boy, feeding choices — and continue every day (or so it seems) until your child is truly capable of making mature decisions on his or her own. This chance to teach is yet another reason many of us became pediatricians, and we relish and enjoy it.

We CANNOT make those decisions for you, however. They are often very personal, and each family will look at the choices through its own eyes. What is right for one family is not necessarily right for another. But we CAN support you in the decisions which you do make, as long as they do not pose a threat to your child’s well-being.

We CAN be available by telephone, and after hours, especially because we realize that children do not get sick only during business hours on weekdays.

But in most cases we CANNOT treat your children over the phone, without having a chance to see and examine them. We trust your reporting as a parent, but we need to make our own diagnosis.

We CAN respond to your concerns about your children, and answer your questions.

But we CANNOT make you ask those questions in the first place. If something concerns you, please ask. There are no stupid questions.

Apart from direct medical issues, we CAN help you deal with your health insurance company. Sometimes health insurance seems like a mystery wrapped in an enigma—but only the company knows the rules and answers. This is frustrating for your pediatrician, for sure, and many times more frustrating for you who have obtained the insurance. We can follow the insurance company’s rules, as best we understand them. Remember, however, that the insurance is a contract between the insurance company and you, not your pediatrician.

We CANNOT do things or provide care which is not covered under the terms of the policy that you have chosen, unless you understand that payment for these services will be your responsibility and not that of the insurance company. And we cannot get the insurance company to pay for things which are not covered in your contract with them.

We CANNOT write “letters of medical necessity” for specialized infant formulas, for example, when your insurance policy specifically states that it does not cover nutritional products. We CANNOT change the date on an office visit or report a diagnosis which does not exist in our medical records, simply because that would allow the insurance to pay. We CANNOT put someone else’s name on a prescription, simply because that person has better prescription coverage. These actions constitute insurance fraud, and put a physician’s license at risk.

We CAN treat many common and not-so-common pediatric problems in the office which is most familiar to you and your child. If the problem is beyond our expertise, we CAN work with you to get needed specialty care, and provide referral forms as required by your insurance. We CAN refer you to the best specialist who is in your insurance company’s network.

We CANNOT back-date referrals if you have seen a specialist without getting the required referral. And we CANNOT fight the insurance company for out-of-network referrals when there are in-network specialists who can serve your children.

Most of all, we CAN be a resource and a support for you as you navigate the course of what is undoubtedly both the toughest and most rewarding task that any of us will likely encounter. By treating each other with mutual respect, and having reasonable expectations of each other, parents and pediatricians can build a warm, long-term relationship. After all, we all share the same goals—watching the growth and development of happy, healthy children (and even, dare I say, grandchildren.)

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.


Why Can’t The Pediatrician’s Office Tell Me What Services Will Be Covered By My Health Insurance Company?

Written by Cliff Wu M.D.

Medical insurance in the United States has to be one of the most complicated and frustrating systems that a family can endure. One question that has arisen recently has been whether a clinic can tell what services are covered by a given insurance plan and whether or not our clinic is in network.

Unfortunately, the answer to both of those questions is no. We frequently do not have access to that information because of all the different insurance plans, and each plan will have different variations. For example, we can be in network for Branch A of Insurance X but not for Branch B within Insurance X and there is no way for us to tell until after we submit the bill to Insurance X. In fact, we won’t even know that there is a Branch A or a Branch B. Of course, that doesn’t help when we try to determine whether we’re in network at the appointment time.

So what’s a family to do? The only answer we have is for each family to check with their own insurance company about what benefits are offered and which clinics are in network. The insurance carriers will release a book every year with which clinics are in network; they may also post clinics and doctor names on their website. Even then, it’s not always foolproof because the carriers may or may not keep these resources up to date.

As pediatricians, we would absolutely love to be able to streamline the process for families, verify our network status, and determine the coverage and benefits, but we simply do not have access to that information, and we are just as frustrated by this process as the families that run into this problem are. Again, a family’s best bet is to check with the carrier using the policy number in hand because that is something that we cannot do until it is too late.

This piece is just a small part of American healthcare complexities. If you are interested in a bigger picture of this nightmare, Planet Money did a blog and an eye-opening podcast entitled “The Pain-In-The-Butt Index” in July 2010 that details the staggering burden that we all endure.

Dr. Wu is a practicing pediatrician in Lakeville, MN. He runs a family-oriented practice built on love for children and the desire to make them feel comfortable with healthcare.