Monday, July 19, 2010
How insurance companies help kill primary care
Most doctors have a love/hate (and mainly hate) relationship with health insurance companies. We struggle with their confusing and complex coding rules in an effort to be reimbursed for our care of patients. When patients leave the office, they may think that a bill is sent to their insurance company and payment follows. More often than not it rarely happens that way.
I am staring at an explanation of benefits (EOB) from Blue Shield of California for a patient I saw for a physical exam and Pap test. This patient had recently been hospitalized with a life threatening throat infection and abscess and saw me for needed follow up. I spent about 45 minutes with the patient, reviewing the events leading to hospitalization, coordinating the medications, as well as addressing the routine screening and examination of a middle aged woman with some chronic health problems.
I billed Blue Shield for a 99215 (comprehensive physical) and a G0101 for the Pap test exam and processing. Blue Shield has reimbursed me $25.55 and states the patient owes another $25.56 as a copay. The EOB says they will pay zero ($0) for the exam because "This procedure is included with the payment for the primary procedure."
Yes, they have decided the $51.11 for the Pap test is payment in full for the entire visit. This is called "bundling" the payment and they have chosen to bundle at the smaller amount. The 99000 code for handling of the specimen is denied as "These services are not eligible for separate reimbursement."
Thanks, Blue Shield (annual revenue $9.7 billion). That is one reason only 2% of medical students are going into primary care internal medicine.
Toni Brayer, FACP
Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Labels: health insurance, practice management, primary care shortage, reimbursement, Toni Brayer
posted by Toni Brayer, MD at
1:00 PM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
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Albert Fuchs, MD, FACP,
graduated from the University of California, Los Angeles School of
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spent three years as a full-time faculty member at UCLA School of
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David Katz, MD
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Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
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FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
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John H. Schumann, MD, FACP, provides transparency on the workings
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
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Kimberly Manning, MD, FACP, reflects on the personal side of being
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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
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American
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White Coat Rants
One of the most popular anonymous blogs written by an emergency
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3 Comments:
This is a sad state of affairs. I read this AM that Blue Cross-Blue Shield has retained more than 3X the recommended surplus at the same time they are raising rates over 30%. There is a definite connection between what happened to you and your payment and the obscene profits that health insurers obtain. Does anyone really care?
This is insurance company strategy to get out of paying we physicians for care we've provided. You have to rebill, or appeal that claim with all the complex billing silliness that proves you deserve the money you asked for. It's why my medical biller takes 5.5% off the top of all money I receive for providing medical care to my patients. 5.5% of healthy care costs just to BILL! That's a lot of money given the amount we spend on health care as a nation.
Cynthia Bailey MD
http://www.otbskincare.com/blog/
I find it amazing that people are getting all upset about government involvement in their healthcare as if it means they are doomed. They don't realize all the issues that are already impacting their health care.
I have a great internist but the last time I called they couldn't get me in for 2 weeks! Luckily I have had enough face time with her (she managed my pneumonia earlier this year and helped me stay out of the hospital this time) that I am able to send an "email" through her office portal and then she'll call in a prescription for me as long as it's nothing unusual.
If I were in medical school I wouldn't go into family practice or internal medicine as it would be impossible to pay off all the student loans. Also, why work your tail off taking care of people AND fight with insurers to get paid?
My cosmetic dermatologist has the easiest life of any of my doctors as she does lots of botox, fillers and laser work and gets paid in full by the patients. And I bet she rarely gets calls at home.
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