Healthcare office visit cost?! Lawbeef or someone? :D

[Carpet_pissr]

WTF man. I finally started going to a GP again after several years of....not.

First bill I get from this guy (and he is in a "system" well known to my wife's above average state gov health plan) is like $700?! For an office visit. I called the office and before I could get the sentence out, questioning the bill, the person was already saying "OK, we will have an audit done on this and get back to you". OK, great.

Now the new bill is for $276, which I still think is bullshit, personally. At first I thought it was because he had requested some unusual labs or something (I had bloodwork done), but when I looked more closely, it's the office visits!

Collection Venous Blood,venipuncture
$7.00
Complete Cbc & Auto Diff Wbc
$34.00
Lipid Panel
$86.00
Metabolic Panel,comprehensive
$44.00
Office/outpatient New Moderate Mdm
$364.00
Office/outpatient Established High Mdm
$324.00

And on the actual bill it shows:

Total charges: $859
Adjustments: -$473
Ins. payment: $98 (?!)
Total due: $274

To put things in perspective, we usually pay around $100 for an office visit PLUS annual, typical lab/bloodwork.

Not sure if this is something I need to continue pursung with this particular (and apparently very expensive!) doctor's office, or try to go through Blue Cross Blue Shield? I've already gone through the office once, and yes, the bill went down, but it still seems VERY high and well above normal.

Anyone with experience in this stuff, would love to hear from you. It's not a huge amount, but it's the way it's being presented...just feels like they are seeing how much I will pay or something.

[Freyland]

I'm a physician. Was in office for 8 years before becoming a hospitalist. I see one thing reassuring and one thing very not reassuring.
Part of the bill is the cost of actually running your labs. That tells me that this office has its own lab rather than using the local hospital system. That is acceptable, and your rate for the labs are acceptable. The only downer is that your doc is potentially tempted to order more labs than necessary since it's profitable.
The major flag to me is that you were charged for both a new patient visit AND an established patient visit. Absolutely sure removing one of those was the "adjustment". Problem is, that's also fraud. You could certainly review this with your insurance, which will likely get the office in trouble, and protect others. Regardless, you should GTFO.

[gilraen]

Here's what that MDM gobbledygook breaks down to (or should) - https://www.idsociety.org/globalassets/idsa/clinical-practice/em-office-visit-reference-guide-01-19-2021.pdf. You may want to get the actual list of codes that your doctor submitted to to the insurance company (get it either from the doctor's office or from BCBS themselves).
And as Freyland just mentioned, including CPT codes for both new and established patient encounter on the same visit is fraud. If they consider you a "new patient" because you haven't been in a while - any many GP offices do - then they cannot submit a code for an established patient just because they "reviewed" your existing medical history.

[LordMortis]

My two cents. That and another $1.79 and you can get a cheap loaf of bread for $1.79. (Guess who did jaw drop with his grocery shop today.)


Doctors both play games and don't necessarily code the way you'd expect. It's difficult to know which is which. Chasing a buck or not being that close to your specific insurer.

You have a few things to sort through and with any luck your company has an advocate group. If they do, use them. My old work used a place called HealthCare Advocate and those guys were the whip. A good advocate are a godsend as your insurance changes every year according to laws and arbitrary reasons and an advocate do your legwork for you...

So

1) If you are only going annually, you want to make sure you are going for a wellness visit. This is covered by the ACA almost in its entirety. (Though it's bit late for that)
2) You want all your labs to be preventative, not for monitoring purposes. That coding change will cost dramatically different for the same thing. If you go in for lipids as part of routine screening, cheap. If you go in for a lipid panel because they are actively checking on heart problems. Expensive.
3) If your bloodwork or a procedure is not part of the ACA coverage, it's likely not part of your visit making your visit not a wellness visit. It's paying a different kitty. So your office visit is still only $20 or $30 or $50 or whatever your copay is but all the first four items come out of a coinsure/deductible separate for the office visit. Under most plans, if it's not in the ACA then $7+$34+$86+$44 will come out of your deductible first, then when you hit your full deductible you have like 80 or 90 or whatever % coverage until that is fully met at you max OOP cost for the year.

My guess, $171 in labs was out your deductible and your office visit cost is a crazy $100. If you had just gone for an annual wellness visit, it would have "just" been the $100.

Also you should be able to go to your BCBS online page and see exactly how things where coded and broken down and covered or not covered. BCBSM are really good. I miss them dearly.

[Carpet_pissr]

Thanks, all for the feedback, and I forgot we had a resident Dr. on here! Sorry Freyland, should have put up the bat signal with your name as well.

Also, I am an idiot, and apologize for time possibly wasted here:

This bill includes TWO separate visits (details are on the BACK...DOH!)...the initial visit as a first time patient, and I asked him to do annual bloodwork/blood test, labs, whatnot since I had not had that done in a few years. That one was $217 after all the adjustments.
The second bill, for $57 after adjustments (Office/outpatient Esablished High MDM) was one month later, and no lab work.

I guess they just lumped two visits into one bill since I went into shock with that first bill for $700, which they offered to audit (so I didn't pay it), and now it appears that it's down to $217 after adjustments (still high IMO). The second, follow up visit was just an office visit, for (again, STILL seems high for that!) $57 after adjustments.

I just wonder if it seems a little high because of the system this doc is in, or the way that they coded it, or maybe something else? I thought it was odd that I could get into see this guy almost IMMEDIATELY in a sea of calls trying to get new patient appointments (for recommended docs) where people were almost laughing at me. Also, there was NO one in that office when I got there....like,....I signed in and BOOM I'm in the back. That never ever ever happened when I went to a doc that was pretty well known (locally obviously) for being amazing. Might be unrelated to my current questioning though.

[Freyland]

Without delving into your medical history or what was addressed, it is hard to say if your visits justified the high codes. I will say that the actual costs for those codes seem high, but I have been out of the office for awhile now. On the bright side, I would expect that the insurance would balk if an office was charging higher prices for a given code than was standard; fraud in these cases is more often using a higher code than what was merited based on the visit.

Now I'm really curious about the audit; suspect doc did what I mentioned just above, and over-coded.

[gilraen]

$217 for an office visit seems insanely high to me. That's almost as much as an average urgent care visit (in Colorado, anyway), and those INCLUDE basic labs.

Edit: I think I misread the part where your $217 did include the labwork, since they itemized the office visit and the labs separately, and then conveniently didn't itemize the adjustment.

[LordMortis]

This bill includes TWO separate visits (details are on the BACK...DOH!)...the initial visit as a first time patient, and I asked him to do annual bloodwork/blood test, labs, whatnot since I had not had that done in a few years. That one was $217 after all the adjustments.
The second bill, for $57 after adjustments (Office/outpatient Esablished High MDM) was one month later, and no lab work.

Two visits at $50 a pop plus a $171 in labs if you have any deductible whatsoever does not sound like gouging to me. If coding is the cause of the lab costs, the question is could you expect anything different. You can call the doctor and insurance company but again I suspect your only way out of that cost would have been to have the lab work done as part of your wellness visit and that ship will have sailed. I recommend going over your insurance package.

the initial visit as a first time patient, and I asked him to do annual bloodwork/blood test, labs, whatnot since I had not had that done in a few years.

That sounds kinda crappy of the doctor. If you specifically say you are doing your annual then that should be how they bill and most stuff should be covered. I might object to those costs.

https://www.healthcare.gov/preventive-care-adults/

Here's a fun one for you. On my insurance, a colonoscopy is preventative every five years beginning at 45 and covered 100% but because I have crone's and actually need a colonoscopy every five years, it comes out of my deductible and co-insure. Yay coding!

[Carpet_pissr]

Yeah, the lab costs seem more or less in line, it’s those crazy high office visit costs…for a standard, GP office visit.

[LawBeefaroni]

Didn't see this until now.

Without having details I can only guess but here's what it looks like.

The first bill for ~$700 was probably without the adjustment. The adjustment is the contractual reduction from the insurance (BCBS in this case). They just balance billed you for whatever insurance didn't pay. This is an all-to-common billing error. Always ignore statements from the doctor/hospital until you have an explanation of benefits (EOB) from your insurer. The EOB breaks down what you actually owe by their calculation, which is usually more accurate than the providers calculation.

The "audited" bill doesn't look too out of line, depending on your plan benefit design. The charges for the office visits may look high but no one pays actual charges. The EOB will indicate what the provider is getting paid per visit. For moderate complexity E&M, 99212 (established) and 99204 (new), anything from $80-150 wouldn't be shocking. Higher for new.

[LawBeefaroni]

the initial visit as a first time patient, and I asked him to do annual bloodwork/blood test, labs, whatnot since I had not had that done in a few years.

That sounds kinda crappy of the doctor. If you specifically say you are doing your annual then that should be how they bill and most stuff should be covered. I might object to those costs.

https://www.healthcare.gov/preventive-care-adults/

Here's a fun one for you. On my insurance, a colonoscopy is preventative every five years beginning at 45 and covered 100% but because I have crone's and actually need a colonoscopy every five years, it comes out of my deductible and co-insure. Yay coding!

If you address any conditions or complaints at the visit they may not code it as an annual.

[Carpet_pissr]

the initial visit as a first time patient, and I asked him to do annual bloodwork/blood test, labs, whatnot since I had not had that done in a few years.

That sounds kinda crappy of the doctor. If you specifically say you are doing your annual then that should be how they bill and most stuff should be covered. I might object to those costs.

https://www.healthcare.gov/preventive-care-adults/

Here's a fun one for you. On my insurance, a colonoscopy is preventative every five years beginning at 45 and covered 100% but because I have crone's and actually need a colonoscopy every five years, it comes out of my deductible and co-insure. Yay coding!

If you address any conditions or complaints at the visit they may not code it as an annual.

Great, so I talked my way into a higher bill than was necessary! Stupid mouth!