Blog | 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.