22 August 2011

Maybe you shouldn't talk to your health care provider

During Susan Scholbrock’s annual physical at UW Health... she had a nice chat with the nurse practitioner. And that was that.

In the mail came a bill for $49.88, approximately 20 percent of the cost of her visit.  However, her insurance company is supposed to pay 100 percent for a physical.

Scholbrock noted that the physical was coded as an “Outpatient Office Visit,” for which, indeed, her insurance company only pays 80 percent.

She called billing to report a coding error... but was told that the visit was submitted as a physical, and her insurance company did pay 100 percent. Since she and the nurse practitioner discussed health in areas not covered in a physical because they are not preventive, there were two charges, not one. So she was charged for two appointments.

“Who knew,” she said, “that talking about one’s health during a physical is not part of a physical and not preventive?”
Ridiculous.  Further details at the Wisconsin State Journal.


  1. When I went in for my physical in June, I was given a sheet by the receptionist detailing just this. A physical was defined as a basic *physical* examination. If I had questions about, say, how to deal with the high blood pressure discovered during the physical or a pain in my knee, that would be billed as a separate visit and would be billed by my insurance as a regular office visit. I guess it has something to do with the new health care laws requiring insurance companies to pay 100% of maintenance care and the insurers then lowering the amount they will pay to physicians for such visits.

  2. John Hollandsworth, M.D.August 22, 2011 at 8:27 PM

    #1 I am a practicing family physician

    #2 I have been taught this exact way to bill in magazines, seminars, and by my employer. It is considered by all medical associations and insurance companies as proper, legal, & ethical.

    #3 I have never done it. I think it violates basic patient expectations and the golden rule.

    I think this points to one of the central issues facing American medicine: its departure from viewing itself as a profession. I remain a physician because it is my joy, honor, and privilege to care for people. I also pay my bills and support my family by it, and so I do charge for my services. But it is not a job, not a business, not a way to churn profit, not a way to make enough money to make up for my disillusionment with life. It is my profession. But that perspective is, I fear, fast fading away in this country.

  3. Thank you, Dr. Hollandsworth! Fortunately, I have Kaiser, a not-for-profit HMO. My primary doctor is someone with whom I can talk freely, and whom I can email with questions outside of appointment time. Referral to specialists is at the discretion of the primary care physician--no one sitting in an office has veto power over the doctor.

  4. Most of us living in the UK agree that the NHS is broken to a certain degree, but despite its failings and its increasingly desperate need for an overhaul, I for one am incredibly glad it's there. I spoke to my local nurse practitioner last week about a minor health concern, and it didn't cost me a penny. After that I went to the pharmacy and got two months' worth of medication for a £7.40 prescription charge. If I get knocked down by a car tomorrow I'll be rushed to hospital no questions asked and treated for free, and that thought gives me a lot of comfort. (But don't get me wrong - I still take care when crossing the road ;) )

    The national health service is one thing that this country has done right, and I think we need to take more pride in it. We might complain about the NHS, but I suspect every single one of us would fight to keep it.

  5. I, like Anonymous, live in the UK, and the NHS is one thing I am greatly thankful for (especially whenever I hear some stories about American healthcare). It is an institution I hope our country will always safeguard.

  6. I work in the business office of a large scale doctor owned practice. Next to me are some customer service staff who get calls all the time about a being billed a copay or having the "20%" balance from the other office visit. We tell them that it is called a 'split visit' because they talked about stuff other than ROUTINE PHYSICAL stuff. Having a cough or a runny nose or a headache is not routine. Doctors have to bill according to what was done/discussed. Simply ask your doctor if they are going to charge you for talking about 'anything else' and decline to discuss anything other than what is covered under the Routine visit guidelines. See the Dr. Hollandsworth point #2.

  7. I live in the UK, and for all its faults (which are very different from those espoused by most of the media and politicians) it's great. Yes, we pay for it - but what's wrong with that? This is a (largely) civilised country and we have a (largely) civilised approach to public medicine.

    I've never really understood the fear of some Americans of a public healtcare system.

  8. ^^ Agreeing with Skipweasel.
    I honestly don't understand the arguments against it - it baffles me.

    I'm more than happy to pay my taxes when they're going to a worthwhile service that benefits everyone. I'd much rather do that than pay thousands to some crooked insurance company that will do their best to screw me over for profit, leaving me with financial problems for the rest of my life.


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