[Kelley A Beloff, MSW, is a Certified Medical Office Manager. For years, she has dealt with the real world issues of HIPAA, PHI and other regulations that dictate how she must run her (very busy) physicians' office. Today, she offers her insights -- and the benefit of experience -- to InsureBlog readers. Enjoy!]
When I got into the office this morning to start another day in a busy doctor’s office, I did my usual routine. Backing up the computer program, going on line to check my emails, and there it was: another article about the costs of health care.
As a Health Care Professional, I strive to keep up to date with all information relating to the health care field. This article was from USATODAY.com and titled “Shopping for Health Care Prices can be pretty confusing.” As I read the article, it was obvious that the author did not talk with anyone who actually works in a physician’s office, so I thought I would correct some misconceptions related in the article. There is a quote from Dianne Kiehl, Executive Director of the Business Health Care Group of Southeast Wisconsin. Ms. Kiehl states that “(i)f you walk into a (doctor’s office) and ask, ‘What does it cost?’ they can’t tell you. (The medical industry)…is trying to keep this information a secret.” This statement is not only incorrect, but shows a lack of knowledge of the operations of physicians’ offices. Firstly, physicians and their staff are not clairvoyant, we cannot predict what treatment each patient will need prior to any appointment. While there are set fees, such as the office visit (CPT Code 99213), there are other factors which can influence the cost of an appointment: A patient can come in for a visit for an illness, but during the course of the visit the patient reveals that two days ago she fell and twisted her ankle. Suddenly, the appointment has gone from an office visit for an illness to a visit for an illness and a possible bone break or fracture. The appointment has become more complex, the physician needs to order an X-ray, the staff may need to set up the patient, and the appointment becomes more costly due to the higher level of medical treatment. This happens in our office frequently and this exact scenario happened to me with my daughter. Since each appointment with a physician is unique to that patient’s care, it is impossible to predict or “quote a price for care” prior to the appointment. The article continues and discusses how “insured patients are going to spend more of their own money, not just on premiums, but every time they go to the doctor, pick up a prescription or get admitted to the hospital”. This is true, but the article does not discuss the reasons why. One scenario that continues to happen in my office regarding patients paying more at their appointments has to do with Medicare versus Medicare HMO’s. Patients are not informed regarding the differences between the two, which causes major problems in the doctor’s office. First, patients believe that Medicare and Medicare HMO’s are the SAME. Time and again, I need to explain that these policies are not the same, in fact there are fundamental differences. Most common is the misconception that if a physician accepts Medicare, then they will accept the Medicare HMO. This is not the case: the physician’s office will only accept that HMO if the physician is contracted with the HMO’s company, e.g. Anthem, Humana, etc.
Patients do not know this fact until after they have signed with the company, seen their doctor, the doctor bills Medicare (since the patient thinks they are the same, the patient does not inform the office that they have a new insurance; it is not “new” to them), the bill is denied and the physician’s office bills the patient. At this point a month to several months have gone by, the patient has seen several doctors and suddenly has a pile of bills. Who does the patient blame: the insurance company, the insurance salesman, themselves, or the physicians office? I will give you a minute. The answer: the Physician’s Office. Why? Because we did not inform them that they were not covered under their “new” insurance (remember, they did not inform us of the change) and now we expect them to pay for their medical coverage. If they had known that the physician did not accept their “new” insurance, they would not have been seen, therefore it is our fault that they owe us money.
Secondly, the Medicare HMO may not pay for the services that Medicare was paying for and suddenly the payment for the same physicians appointment has increased. Again, who is to blame? Again, the Physician’s Office. “Why are you charging more for the same treatment I received last month under Medicare?” We are not charging more, your Insurance company is covering less of the bill. The charges are the same; there has been a change in how the bill is divided between the insurance company and the patient. This also relates back to why we cannot tell each patient what their care will cost prior to the appointment. Each insurance company pays based on it’s own internal calculations, and many time the physician’s office will not know the cost to the patient until the Explanation of Benefits (EOB) arrives in the mail. What this article tiptoes around, but what I tell my patients, is that the patient is responsible for all the aspects of their own health care. This means understanding the insurance policy prior to signing anything, knowing if your doctor is in-network or out-of-network (i.e. takes your insurance or does not take your insurance) and finally, you the patient are ultimately responsible for all health care costs incurred by you.
I would like to thank Hank for letting me inform your audience.
Kelley A Beloff, MSW, CMOM
[ed: You’re welcome!]
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