Wednesday, April 9, 2014

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse
Healthcare Specialist, Patient Advocate, Certified Mediator

Ten Services Your Physician 
 might soon bill you for*

In the "olden" days, which are actually not that far behind us, patients paid their co-pay at the window at each office visit, and would receive a bill for any balance owed later. All administrative tasks were covered under that visit payment. Getting a copy of records was free, as was getting a form signed. 

Things have changed. Be prepared to be asked to pay for certain of those "non face-to-face" services. Almost always, they are rejected as "inclusive" or "not covered" by insurances. Depending on  the insurance Explanation of Benefit and on the medical practice's policy, these fees might be reflected on your next statement. 

A. What are some of those charges?

      1.Copy of Records

Although records are about you, be aware that only the information is yours, not the actual reports. It is widely accepted that an office may recoup the cost for paper, CD, staff time, postage, etc. In some states, this was approved by the legislature and fees have been set.

      2. Review of Records:

Reviewing outside records or of your updated medication list is part of the visit with your physician to establish a diagnosis or prescribe the right treatment. More unclear is the status of reports sent by satellite medical providers or therapists whose advise is not necessary in the decision making process. 

      3. E-visits:

Telemedicine visits are up. You may now consult a specialist out of state, "visit" a nutritionist, or discuss your care with your MD without leaving your home. While some insurance carriers have started covering the cost as a cheaper alternative to an office visit, many do not.

    4. Electronic Communications

Many offices encourage patients to use a web portal to directly access Electronic Records or email requests and questions rather than calling the staff. 

   5. Handling 

"Handling", commonly seen on statements, reflects the extra "stuff" the office personnel has to do to complete a doctor's order (process blood samples, call prescriptions in, send samples to an outside lab, discard fluids securely, sanitize equipment). Insurers never pay those extras, as they are part of the main service.

   6. Letters (of Medical Necessity) and Statements

Need a Jury Duty excuse? A handicapped placard? Justification to avoid a trip cancellation fee? Your physicians' signed letter of medical necessity often is your only recourse. 

   7. Forms & Applications 

If filing for medical leave, disability, or apply for benefits, the process either begins with or eventually requires your physician's assistance. 
Applying for assistance programs from drug manufacturers or charitable organizations will also result in questionnaires on your MD's desk. 

   8. Supplies

These charges can mean anything: the syringe used to draw your labs, the cast on your broken arm,  the IV tubing for your infusion. Only some are included in the cost of the service.

   9. Family Conference

The time spent educating your loved ones when facing a serious illness or intervention takes a toll on your MD's patience and time. 
Scheduling a family conference for a longer-timed appointment allows for an unhurried discussion.
  10. Multi-physician Conference

More efficient than physician-to-physician calls, this conference gathers every medical team member involved in your care to establish individual oversight responsibilities and discuss your ongoing care. 

B. What is included and what is not? 

Any step necessary to perform or complete a doctor's order is considered "inclusive" and is not payable separately. Though every step is separate, only one final product ("lab", "infusion") may be billed. 
If the office visit implies latex gloves, paper on the exam table, the review of your medications or a Band-Aid, these are inclusive to the visit. 

Anything "extra" such as medications or durable medical equipment (implantable pump, cast) is payable in addition to the base service. So is the use of specific equipment (imaging, EKG).  
You can be billed for the use of the X-ray machine plus the fee of the doctor reading the results, but the cost of the film is inclusive. 

In general, anything labeled as "supply" or without a specifically assigned descriptive billing code is likely included in the global fee. 

C. Should I pay?

Certain fees such as handling, many supplies, electronic transmissions are not your responsibility. You should not pay for any charge that your insurance has rejected as "inclusive". 
If charges are denied as "not a covered benefit", or if you are a self-pay patient, the office might bill you. Check your Explanation of Benefit: is the charge listed as a contractual adjustment, or as your responsibility? 

Other services (letters, applications and copy of records) fall under the discretion of each medical practice. Consult your State's Insurance Commissioner's Office on the applicable guidelines and on your rights. 

Sending prescriptions or approving refills, requesting authorizations, filing appeals, and other similar administrative or billing tasks are the responsibility of your physician and may not be billed to you.

Services requiring the actual involvement and expertise of your physician should be paid by you, even if your insurance does not (e-visit, family conferences). Most offices will schedule them as a "cash only" appointment. You should pay them.
As for for multi-physician conferences, they should be reimbursed by your insurance, or by you in the alternative. 

Any review of records, as part of your immediate medical care, is inclusive, even if done on a different day than the actual visit. 
If asking your doctor to comment on an article you found on the internet, expect to be asked for a fee in the near future. Unless they are necessary for the MD to perform his duties or for your safety to be safeguarded, you are hiring her for a side job and should be prepared to compensate her for that time.

Some costs (i.e. e-visits) might be deductible as a medical expense on your tax return or be eligible under your HSA or FSA account, even when denied by your insurer.
Please visit for detailed info. 

D. In conclusion: 

This shift in charging patients for office staff or inclusive services is likely to grow. Pressure is mounting on insurers to reimburse some of services (e-visits especially). 

Until the healthcare system in flux stabilizes, expect to be hit for services previously free of charge. While some fees are justified, many are not.

Your explanation of Benefits is your road map. But you may not want to argue every charge. Just as you do not work for free, neither should your physician.

* As seen on NerdWallet:

©  [2016] Advimedpro.
©  [2016] Martine G. Brousse.
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My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements

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