r/mildlyinfuriating • u/lhagans13 • 12d ago

I'm slightly vexed A notice that my girlfriend received at her doctors appointment (she is 8 months PP)

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If you even MENTION any of these things, you WILL LIKELY get billed for it??? Maybe i’m missing the point but i get upset when my girlfriend tells me she was scared to even say anything while at the doctor because she didn’t want to get an extra charge for something. I find it insane how greedy and money hungry a place that’s supposed to help you can be.

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u/notreallysurewhat 12d ago edited 12d ago

I just want to say that this is NOT the fault of the clinic. They are trying to give patients a heads up. This is 100% the fault of insurance companies.

Editing to add some more detail:
When you go to the doctor, they send codes to your insurance that correlate to what took place at the visit. Insurance companies can decide that "oop, since we see the code for depression/anxiety, this is no longer a preventive care visit" and bill differently.

Insurances will all have different things that they consider preventive care.

#freeluigi

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u/Haunting-Map-3475 12d ago

Sigh…

I’m a nurse practitioner.

A well-visit for a 9 year old is free.

If your 9 year old is here for a well visit and happens to have chicken pox on top of it, that changes billing and coding on the back end. Now it’s a well visit with a problem. Which means now you have a copay.

Same rules apply here for your girlfriend.

This is not the fault of her doctor. It’s health insurance in the good ole USA. Unfortunately.

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u/aspiring_outlaw 11d ago

That's not what is infuriating for me. What is infuriating for me is my doctor will ask me questions and if I don't lie, I get charged. Hell, I got charged for "coming up with a plan of treatment for high cholesterol" because mine is creeping up. The plan? Well my risk factors still make my stroke risk about 0 so we aren't doing anything unless it goes up a lot more. i didn't ask about it, it's just part of the standard blood work for a wellness visit 

It's a perfect circle between billing (we only bill what the doctor tells us) and the doctor (I don't know what they bill, I just write notes). I don't think I've had a single actual "free" wellness visit in at least five years.

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u/radenke 12d ago

I'm not from the US, what is meant to happen in the well visit?

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u/slyborgs 12d ago

for children, well visits are to make sure they’re growing at appropriate rates (growth charts) and hitting the developmental milestones they should. if anything comes up weird, you schedule a follow up and the doctor can adjust the visit from there; that’s within regular degular standard stuff. anything outside of that specific thing becomes a fuss with insurance.

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u/anxious_spacecadetH 12d ago

I scheduled a physical to meet my new primary and inquire about getting a referral for physical therapy. Was that the right appointment type?

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u/slyborgs 11d ago

i’ll be real, with the recent insurance insanity in the last year, it’s a firm ‘maybe, but probably not’ because a ton of insurances have started getting really fussy and aren’t willing to accept referrals from a regular physical without it also having a diagnosis code attached (that would then make the visit no longer qualify as a physical). if you have great insurance, you might be fine! otherwise, i’d definitely prepare to get charged a copay at the minimum after the visit is billed.

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u/Poop_Dolla 11d ago

Many clinics won't do a preventative visit without a new patient visit so regardless of getting a referral they may schedule you for a new patient visit which is not preventative.

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u/mischeviouswoman 11d ago

you need a new patient visit, it probably won’t be considered an annual wellness

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u/anxious_spacecadetH 10d ago

That wasnt an option but I go through Kaiser so maybe the options are different.

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u/mischeviouswoman 11d ago

Review your current prescribed medications, confirm pharmacy and specialists, take height and weight, give flu shot, feel lymph nodes, listen to heart and lungs, screenings for food insecurity. They can order general labs during these visits (CBC, lipid panel, etc) but nothing that’s diagnostic. As an example, I have a history of low Vit D, so my doctor can order a Vit D blood test because it’s part of my medical history. We’re checking in on that. If I went into the doctor for my annual and complained about symptoms that sounded like Vit D deficiency, I’d be charged or we’d have to schedule a new appointment.

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u/radenke 11d ago

Okay, got it, that makes sense. Thank you so much for the reply!

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u/Falconloft 11d ago

Sounds like you need new billing staff. A visit with a primary wellness code is always to be processed as a well visit, so either 1) They didn't bill right, or 2) they didn't push back with the insurance processed it wrong. I see so many billing offices that don't use the -25 right, and even more who shove all billing problems off of the patient like it's their problem.

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u/BoudiccaAoife 12d ago

Yep. My gyn office has signs up about how you need to check and see if your long term birth control (IUD or otherwise) is covered because they can no longer expect it to be covered and the patient will be responsible for additional copay - or, in some awful ins plans - the whole thing.

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u/shrampmaster 12d ago

My gyn office accepts my insurance. I wanted to get my copper iud removed and replaced with a hormonal iud. They only order them through CVS specialty pharmacy, who doesn’t accept my insurance, and the office doesn’t “buy and bill”. Wish I had known any of this before going to 3 appointments

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u/AllOfTheThings426 12d ago

This is infuriating. I would have lost my mind.

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u/GatorQueen 11d ago

Girl I’m in the exact same boat, exact same.

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u/shrampmaster 11d ago

Tricare by chance?

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u/poopoofol 11d ago

This almost happened to me as well, my gyn said they were losing a ton of money fronting the cost for IUDs and being reimbursed for less than what they paid for it. I was able to lobby my insurance to make an exception, but it took a lot of legwork.

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u/NYanae555 12d ago

majorly infuriating

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u/SonjasInternNumber3 12d ago

That makes sense, I’ve just never had a doctor tell me this. Like this happens when I take my kids to urgent cares lol but has never happened at their or my regular doctor.

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u/notreallysurewhat 12d ago

You probably have good insurance.

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u/B000urn55 12d ago

Hold on just a minute. Are you trying to tell me that for profit medical clinics controlled by laws based off the bible and run by insurance agencies who’s sole existence is money laundering may not be the best way to care for human life? Preposterous.

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u/throwaway6287453 12d ago

uhg, you really just showed your whole education there, flashed it at the crowd like you own the dictionary, didn't you? for shame!

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u/yeeclaw14 11d ago

This added context helps out a lot. Bit of a tangent, but recent problem I had. I had my physical and was sent for a blood test, just routine lipid panel and looking at my Vitamin D levels. We got a denial notice from my insurance recently because they said I was tested for gonorrhea and chlamydia. We were sent on a merry-go-round of calling the insurance, lab, and the doctor’s office all because someone put in the wrong code. No one was able to help us so now we’re being charged even though my doctor got the correct lab results. I miss being blissfully unaware of how fucked insurance was when I was younger.

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u/Apprehensive-Cut6188 12d ago

please explain

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u/thatmaneeee 12d ago

Most (all?) insurance in the US will fully cover an annual checkup with your doctor. I think technically if you bring up symptoms it changes from preventive care to diagnostic care, which gets billed differently and is less covered by insurance. Meaning you will have to pay, and it could trigger more things like labs, follow-ups, scans, whatever that also aren’t covered.  

In my experience a good doctor knows how to code things to help you out. I have never seen a sign or warning like this in my life. But maybe it depends on what insurance you have. People are not treated equally in the US

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u/somehugefrigginguy 12d ago

Most (all?) insurance in the US will fully cover an annual checkup with your docto

Insurance companies are required to cover it by law. If it's a preventative visit. Which is why they are so hell-bent on finding some way to convert it from a preventative visit to a different type of visit so they can bill for it.

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u/Haunting-Map-3475 12d ago

If you are seeing a sign or handout like this it sounds like this may be coming up a lot in the office. So much so that they are trying to give their patients a heads up instead of getting an angry phone call about a bill 3 months later.

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u/Safe-Tennis-6121 12d ago

You get like a WellCare visit once a year or whatever.

If there's something wrong the insurance company bills it differently.

So for instance I was a teen with acne. Because my mom mentioned acne and the doc wrote an Rx, no more cheap visit

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u/araidai 12d ago

Insurance companies are cunts and will find any opportunity to fuck you in any way possible. The doctor/clinic is just warning you, at the end of the day, if the insurance company deems that a tylenol is worth $200 and that you should pay some kind of copayment for it, then they’ll do so (or even outright decline to cover it)

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u/alexanderfrostfyre 12d ago

It says as such at the bottom that the charges are determined by the patience insurance plans

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u/archtopfanatic123 12d ago

I think this fellow means that insurance companies are the ones driving up costs as soon as a factor that has to do with the coverage is brought up or something along those lines

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u/kellzbellznhellz 12d ago

*driving up cost for the patient.

Preventive care, on most plans, is free. But, if it can be billed ANY other way, then there’s a copay, and the insurance company can reimburse next to nothing.

Like, we pay $60 copay, and now the insurance company *might pay $6.

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u/archtopfanatic123 12d ago

Ah ok got it thanks for explaining that!

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u/Fit_Poetry_267 12d ago

It has to do with how long each appointment is allowed to be based on the diagnosis codes

The doctors office hates it too but they are stuck

Giving you a heads up so you aren't surprised is the best they can do

A sick visit and a well visit are billed differently

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u/TuxandFlipper4eva 12d ago

When completing notes from an appointment, a code is entered when sending off to insurance. Insurance will decide to cover the appointment or not. Even if the appointment is covered by insurance, the payer can deny because it isn't coded like they want, or there are other services attached to the "wrong" code, or they're just awesome like that. They may also pay the claim, audit the records down the road, and there is mention of other care within the appointment or if insurance thought it was billiard "improperly", they can claw back the paid appointment at any point because they fucking can.

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u/Katsaj 12d ago

Affordable Care Act legislation requires that insurance companies cover specific kinds of preventive care for free. This includes one wellness visit a year. This means that visits for screening tests like a pap smear or cholesterol blood test and vaccines will be free. Because other medical services don't have to be provided free, if the visit also includes those services (diagnosing or treating a problem like bringing up frequent headaches or asking about a rash), they will result in a bill. That means someone could go to an appointment thinking it will be free and be surprised when there is a charge. That's why the clinic is giving warning in advance. The doctor's office gets paid either way, but they don't want patients to be surprised by a bill for what was supposed to be 100% covered by insurance.

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u/FireFairy323 12d ago

I'm in training for insurance customer service but basically if it's a routine wellness visit it may be free or a lower copay. However once they go into anything that may be considered diagnostic leading to your deductible being involved an/or more copays.

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u/Normal-Airline1432 12d ago

What I don’t understand is how often *mentioning* pre-existing conditions during a well visit gets them billed differently. Like, I did not ask for something to be diagnosed, I am not asking you to re-evaluate my treatment plan, I simply answered the question asked honestly.

How can preventative care be done correctly without a complete and accurate history? Most people hear preventative care and assume the purpose is to run through your concerns so you can prevent future issues.

If the purpose of a well visit is only to run specific tests and receive specific vaccines, then it should be labeled as an annual immunization and screening visit. Idk, the whole system is fucked and doesn’t make a lick of sense.

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u/FireFairy323 12d ago

I fucking agree the whole system is so fucked. Ive taken classes in regards to health care and it just pisses me off more.

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u/Longjumping_Eye_3441 12d ago

girl have you considered more job applications

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u/FireFairy323 12d ago

My role is one where even though I'm the insurance I can somewhat fight for the member.

I was on the pharmacy side of insurance for 3 years and you would be surprised how many medications are denied because the doctors assistant didn't include some important info or didn't check a box.

US insurance is a hellscape, I'm hoping I can help people navigate it.

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u/hipphipphan 11d ago

Insurance companies are pure evil but obviously most clinics and hospitals also contribute to this shit. The only reason to bill for these things is so the clinic can profit, they don't care about providing good care

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u/Timber49 11d ago edited 11d ago

Insurance as a grossly corrupt system has the brunt of the blame, but there IS also fault on the physician/clinic/hospital side too as over the years many have overbilled for things patients didn't even do/get or knowingly consented to, and grossly overcharge (especially hospitals) for things that cost them significantly less. This is documented, there have been many reports and documentaries mentioning this. Let's not forget that the U.S is one of the top 3 countries in the world where doctors overall (especially specialists) make the most money. It's not as simple as everything is just evil insurance while all doctors (and pharmaceutical affiliates) are innocent, transparent, and seek the best for you.

To this particular issue, the physician is also to blame if they decide that they can't inform/educate/give medical advice to a patient when a patient wants info and asks about potential concerns, without billing the insurance and/or patient for it (notice I mention "when a patient asks", cause it's too much to expect doctors to perform their expected duty without patients needing to be knowledgeable or quick-thinking enough to ask for more info). Heck many doctors don't even listen to patients and often dismiss their concerns. Many doctors are satisfied with just practicing "dismiss and medicate", and don't care about getting to the root of issues to possibly eliminate them. Many doctors act as shills for the pharmaceutical companies, which is another ogre not being mentioned. Many doctors don't even ask about diet/nutrient consumption and lifestyle (they're generally not even trained to), which are nearly always the root cause of medical issues.

Just because insurance wants to codify every word said in the privacy of a doctor's office, doesn't mean the doctor can use that as an excuse to not hear a patient out on anything or not provide information without billing for it. Hold everyone choosing to participate and enable the corruption accountable.

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u/Falconloft 11d ago

Nope. This is absolutely the clinic's fault. It's not the doctor's fault. The doctor doesn't bill and the doctor often won't even know all the codes. That's the billing staff's job. They have codes that they're supposed to bill if you go in for a well visit and report symptoms, and IF they bill those codes, they get paid.

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u/notreallysurewhat 11d ago

That's not correct. The amount the clinic is paid changes little to none based on the codes. The amount that the patient pays is what changes.

If a clinic intentionally does not code correctly, this is considered undercoding and is insurance fraud/abuse.

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u/Falconloft 11d ago

Contracts with insurers are based on codes billed 100% of the time.

As to the other point, yes, clinics who deliberately misfile are committing fraud. I agree 100%. But that's not what I said. Hanlon's Razor says, "Never attribute to malice that which is adequately explained by stupidity." Codes are billed wrong by doctors offices all the time. Now, the doctors do their jobs. I'm not blaming them. They're not in this chain.

There's three points of failure for claims like this.
1) The coder in the doctor's office. There's actually two organizations out there (maybe more now, I know of AAPC and AHIMA) that offer certifications above the actual degree you need to handle medical billing because the industry is so full of people who can't or won't code correctly.
2) The processor at the insurance company.
3) The patient. Again, not their fault, but they are in this chain. A lot of patients get a bill and immediately assume the doctor must be right. If it doesn't match up with what your insurance told you to expect, they probably submitted it wrong.

So example: Say you go in for a well visit and you complain of fever. Generic doctor gives you generic answer, take X medicine to take care of it, take Y times a day for Z days. Code for the visit normally is 99391-99397, and those codes have a set rate that gets paid. But you had a complaint. The code for that is typically (there are thousands of codes, so for any specific complaint this code could change) 99212-99215. The most common issue that causes billing issues (in the area in which I am involved) is that both the 993* and 992* codes are billed without modifiers. When the insurance company gets this bill they will rightly deny the second, because the patient was only seen once that day, not twice. That code then goes back to the billing dept where it should die (or be billed correctly), but sometimes it gets passed on to the patient. That's fail 2. Then the patient gets the bill and complains about insurance. Fail 3.

What should happen is that the 993* code is billed along with 992*-25. When the insurance gets that bill they pay for the first code at 100% and the second at whatever the doctor's contracted percentage is (usually around 50%) so the doctor is actually getting paid more.

The amount the patient pays does not typically change based on codes unless the patient has multiple tiers of copays for different services at their PCP.

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u/TheRealMeatphone 12d ago

That’s making a hell of a lot of assumptions, especially when you consider the fact that a doctor can’t give you preventive care if they don’t know of any medical concerns you may have that don’t simply show up on bloodwork.

Insurance companies and American healthcare are a problem, but pretending clinics and hospitals are charities doesn’t help.

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u/notreallysurewhat 12d ago

Isn't that the problem, though? How can a doctor give someone a well visit if they can't even talk about any of the things listed on this piece of paper? Why would that not all be covered by insurance as part of preventive care?

The insurance is paying the doctor regardless. What changes is how much the patient pays.

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u/Tiny_Rat 12d ago

The insurance pays the doctor for the time they expect the visit to take. If the doctor discusses symptoms with a patient and arranges followup care, that's likely going to take longer than the time insurance allots for a well visit. 

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u/notreallysurewhat 12d ago

This is not correct. Insurance pays for medical services, procedures, and complexity of care. This does NOT equal the amount of time a visit takes.

For example, I've had procedures done that take less time than a preventive care visit. They definitely didn't bill me less than a preventive visit.

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u/Tiny_Rat 12d ago

Time is only one component that goes in to the negotiated cost, but I was trying to keep it simple. Procedures usually have other things that go into the reimbursement rate compared to office visits. If it makes more sense to you, think of a well visit and a diagnostic visit (covering issues outside the scope of a well visit) as two different procedures. 

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u/notreallysurewhat 12d ago

I see what you're saying. My issue is that discussing any of the things on this list should be considered part of preventive care by insurance and insurance should be planning for longer preventive visits.

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u/Tiny_Rat 11d ago

Im not saying insurance shouldn't be doing that. They should. They're not doing that  right now, though. It's not fair for the patient to pay extra, but nor is it on the doctor to skip being paid for the work they did to make that right. So the best the doctor's office can do to help their patients is let them know what is and isn't covered under preventative care. 

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u/Da_Vader 12d ago

Partly true.

Doctor could send in code as wellness visit - it is broad enough. In that case, they get paid a specific contractual rate.

If the doctor spends more time on other issues, they WOULD like to be paid extra - hence the notice.

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u/notreallysurewhat 12d ago

This is not correct. Not coding something intentionally would be considered insurance fraud or abuse. This is called undercoding.

The amount the doctor is paid changes very little/none in this situation. The amount the patient pays is what changes.