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Lakeshore
An author of no particular popularity

Jay Lake
Date: 2011-07-01 06:34
Subject: [personal] A tiny little example of why we need healthcare finance reform
Security: Public
[info]the_child went to the doctor last April for a routine well child visit. As it happens, we get our medical care through a teaching hospital and its associated clinics. She was seen by a resident, not a staff physician, as happens in teaching hospitals.

I have since been billed three times for the visit as 90/10 co-insurance pursuant to her deductible under my plan, even though wellness visits are 100% covered under my plan. I have called the hospital's billing department twice, and the insurance carrier twice, and a third time just yesterday afternoon. At this point, I've invested about four hours of my time on the telephone disputing a charge of $85.89. In that time I've been told twice this would be resolved. Yet the bills keep coming.

The problem comes down to this. Because she saw a resident, the visit was billed as "Clinic Services", not "Physician Services". Residents don't have something called a "physician billing code", so they can't be billed as "Physician Services". So even though the service provided is clearly identified to the insurance carrier as a well child visit, because it's not associated with a physician billing code, it doesn't fall under the 100% coverage.

What the hospital billing department told me was that in the future, I should request a staff physician rather than a resident if I preferred the visit to be fully covered.

They said this with a straight face.

In simpler terms, I can pay close to $90 to see a much less experienced physician, or I can see a much more experienced physician for no out of pocket expense. Because of an artefact in the billing system.

Is this what the GOP is always on about when they tell us healthcare consumers to be "wise shoppers"? Because this is a perverse incentive to avoid the residents, who are presumably there to learn, and which process I fully support. But not at an extra $85.89 a pop for the privilege of helping them learn.

This is lousy customer service on the hospital's part. It's lousy educational policy on the medical school's part. It's a stupid problem on the insurance carrier's part. And it's already cost me more in the value of my time to pursue this problem than if I'd just shut up and paid the damned bill in the first place. In four hours of effort I could have written, revised and sold a 5,000 word story for $250, covered the cost of the visit and had enough left over for one of my hotel nights at WorldCon this August.

So please explain to me why ours is the greatest system in the world, and why any efforts to reform it are evil socialism? Because the crap I go through for my healthcare, of which this particular issue is one tiny fraction, doesn't look to me like the greatest anything in the world except the greatest FUBAR.

Or maybe conservatives enjoy mountains of extra paperwork, rebills and endless telephone calls with their greatest healthcare. Me, I'd love a single payer system. Simple, sane, and wouldn't affect my healthcare delivery one tiny whit. Too bad healthcare finance reform is our national psychosis these days. The current system nickels and dimes me to death.

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ubiquitous_a: eddie-scurvy
User: ubiquitous_a
Date: 2011-07-01 14:16 (UTC)
Subject: (no subject)
Keyword:eddie-scurvy
I agree, this is EXACTLY why we need single payer health care. The countries that have it look at us here in the U.S. and think we're all nuts. They're right.
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cathshaffer
User: cathshaffer
Date: 2011-07-01 14:49 (UTC)
Subject: (no subject)
Actually, the reason your well child visits are covered 100% is because preventive care is supposed to be free in 2011 under every insurance policy under health care reform. One thing I wonder is if maybe there's a different reason it's not being covered that way. I was warned by our insurance agent that if you schedule a preventive visit, and if anything non-preventive comes up at all, it's no longer covered as preventive care. So if, in that visit, you got advice on any ongoing health issues, or if the doctor made any kind of new diagnosis, even something like a sinus infection, or prescribed any medication, it is no longer preventative and no longer covered 100%. Just a thought. There's a lot of confusion in hospital billing departments, and a lot of the times (but not always) I've found when an explanation doesn't make sense, it's because it's actually wrong.
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Jay Lake
User: jaylake
Date: 2011-07-01 14:52 (UTC)
Subject: (no subject)
Which could conceivably be the case, except that both the insurance company and the hospital have told me over the phone this is a Well Child visit and coded as such. It really comes down to how the service delivery was classified, and the lack of a physician billing code. They've been consistent in that statement.
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cathshaffer
User: cathshaffer
Date: 2011-07-01 14:56 (UTC)
Subject: (no subject)
So "clinic services" is somehow out of network or something? That is so messed up. Ugh.
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Dave O'Neill
User: daveon
Date: 2011-07-01 15:05 (UTC)
Subject: (no subject)
Well, this is kinda weasely too, because what I'm seeing is that preventative care visits to the Doctor are covered, the tests they do still cost money. So my "free" visit to the Doctor costs me $150 out of pocket for the lab fees...
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threeoutside
User: threeoutside
Date: 2011-07-01 15:08 (UTC)
Subject: (no subject)
I'm fighting a similar battle over the State's Worker's Comp coverage of my work-related injury of last January. It has nothing to do with me; it's the cretinous Providers not sending their bills to the place I told them to; instead they send them to my BCBS, which rightly refuses to pay them. I call the provider's (outsourced) billing number and learn that those idiots, when I'd called months ago and given them EVERY SINGLE PIECE OF WORKER'S COMP OFFICE CONTACT INFO THEY NEEDED INCLUDING MY CLAIM NUMBER, mixed the Worker's Comp contact, my own employer's agency, and the BCBS addresses and phone numbers in some kind of ecstasy of insane confetti-blending. If I had not called them - something I shouldn't have to do because none of this has anything to do with me any more - NO one would have found this out, and they would have continued sending ME bills, eventually handing it over to a collector and probably damaging my credit rating. *steam*

Anyway, my original reason for posting is to remind everyone that actually taking care of people has nothing whatsoever to do with what the Repubs want. What they want is NO government, and rule by the mighty and rich few over the sick, starving, cowed masses. Keep that in mind and this kind of insanity will make much more sense to you.
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Kari Sperring
User: la_marquise_de_
Date: 2011-07-01 17:07 (UTC)
Subject: (no subject)
That is deeply, deeply stupid on the parts of both the hospital and the insurance company.
I much prefer our evil socialism. But then again, I would.
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miki garrison: bridge troll
User: mikigarrison
Date: 2011-07-01 17:23 (UTC)
Subject: (no subject)
Keyword:bridge troll
This is a peculiarity somewhat specific to OHSU -- at every other academic medical center I've been to (an the N is high on this), resident visits are billed under the attending physician who is supervising them, since that attending is the one taking ultimate responsibility for both the care being provided and the accuracy of the diagnostic and procedure codes being billed. Why it doesn't work this way at OHSU is beyond me -- they are losing money on it this way themselves, plus costing the patients extra money out of pocket. It's a lose-lose; the only group who wins is the insurance companies, since their cost is significantly lower than it would have been for a physician visit.
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John
User: djonn
Date: 2011-07-01 18:07 (UTC)
Subject: (no subject)
Crossposted; this ties in with what I was discussing below, I think. There may be differences in the way OHSU classifies "staff physicians" (i.e. outside contractors) vs. teaching faculty (i.e. University employees) that contribute to the confusion.

I am not so sure about the insurance companies "winning" the equation, as their 90% share of a "hospital" rate for a given service may be about even with 100% of the "physician" rate for the same service. This goes back to the systemic presumption that primary care from hospitals is inherently more expensive than primary care from physicians.
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John
User: djonn
Date: 2011-07-01 17:47 (UTC)
Subject: (no subject)
I'm going to consult my expert source on this, but I think the issue here is not so much that your insurance is trying to discourage people from getting primary care from residents as it's trying to discourage people from getting primary care from hospitals (because in general, hospitals are not designed to deliver primary care).

Having said that, some amplifications and caveats:

Teaching hospitals (which I'll define as those directly affiliated with or operated by medical schools) may well constitute an exception to the generalization about "not designed to deliver primary care". OTOH, in today's market, university systems might be well-advised to structure all or part of their care delivery organization as a clinic and not a hospital in order to avoid situations such as you're experiencing. [I don't know how your provider may have addressed this.]

The term "staff physician" is likely to be misleading. As I understand how most hospitals work (and again, university/teaching hospitals may work differently), a "staff physician" is not usually an employee of the hospital. Rather, he or she is in private practice (either as a partner/owner of that practice, or the employee of a group practice or clinic), and the private practice has a contract with the hospital whereby the physician receives "staff privileges". By contrast, a resident at a given hospital is usually an employee of the hospital (or at least is working for the hospital directly).

So if I've read this right, when your insurance provider sees a "physician" billing code, it treats your services as being provided by that physician, and pays the physician (or the practice for which the physician works). When the insurer sees a "hospital" billing code, it treats the services as being provided by a hospital, and pays the hospital.

So yes, this is probably an artifact of the billing system -- but the appropriate systemic repair is probably for your "teaching hospital" to more accurately classify itself as a "teaching clinic", so that the insurance claims engine doesn't see "hospital" and jump to an incorrect conclusion. [This may or may not offer an avenue toward resolving your immediate problem, but if you can get your insurer to see the situation this way, it may get them started on the right track.]
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User: mmegaera
Date: 2011-07-02 01:57 (UTC)
Subject: (no subject)
Keyword:quilting
I wish the folks who actually need this mashed into their brains with a machete (who would then be forced to deal with the medical 'system' -- hee!) were listening, and not the choir. [sigh]
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farmgirl1146
User: farmgirl1146
Date: 2011-07-02 05:25 (UTC)
Subject: (no subject)
I agree: single payer, not BS (you can parse this bull shit, bad science, bad service -- need it go on?)

Have you looked at the French model?

Sorry to read of your problems with the child's healthcare billings.
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triskelmoon
User: triskelmoon
Date: 2011-07-02 05:45 (UTC)
Subject: (no subject)
Hey Jay, I actually work at OHSU Pediatrics, so I may be able to escalate this if you need me to...

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tangent_funk
User: tangent_funk
Date: 2011-07-03 01:12 (UTC)
Subject: (no subject)
It sounds to me more of a side affect of economics within large insurance, or many other, companies. If there issue Y in the computer system or Standard Operating Procedures (SOP)then Y is solved. If issue Y(a)occurs and it's neither in the computers or the SOP then the software and the SOP need to be adjusted. Which can cost a lot of money. Large corporations pay ludicrous sums for their custom software (Lets call it S) and any adjustments often costs more ludicrous sums. SOP's also need to be reviewed by a committee, all of whom need to be paid and have costs to cover, which we will call "C".

If the total cost of C + S is greater than the cost of issue Y(a)then it would be economically unsound to pay for C + S.
In your case Y(a) is = $85.89 + the possibility of losing one customer and perhaps a couple of their friends (We'll call this P). Which is still probably a lesser sum than the total of C + S. If Y(a) issue increases in frequency enough to exceed the cost of C + S then it will make economic sense to pay for C + S in order to resolve issue Y(a) and a marketing campaign to regain lost P.

I'm not saying your healthcare system doesn't need to be reformed. As an Australian who travelled through America I was warned about it being the scariest place to get hurt in and I bought the most expensive insurance I could find. In our socialist democracy, basic healthcare is taken care of the mostly by the government and for most of my life it's been virtually free to me personally(though there are private options and the last Liberal[NB: In Australia Liberal=Republican] government eroded some of that away and shifted some more cost onto the public). Which is as it should be. Like roads, schools and infrastructure the cost is too huge and profits too long term and more difficult to record. Having a healthy, longer living, population means more able workers which means more production capacity and a higher GDP. A private corporation's profits are evaluated and targeted for a much shorter time than that of a Country/Society/Civilisation. But I suppose as America can have only have a the same government/leader for a maximum of 8 years it means that it's foresight is not that much more of that of a private corporation.

And I think that America's position as having the 'greatest system in the world' has been a bit of a joke internationally for some time. America kind of has a international reputation as being a big idiot with a big gun. Just be careful to use small words and be nice to him and hopefully he can be your friend. Who would be handy if you needed a strong pair of hands or were attacked by a bear. But the whole time we're a little scared they'll get drunk, or just not pay attention, one day and accidentally shoot you.

I'm not trying to flame Americans. I've met lovely and intelligent ones personally. I even think you've made some fantastic contributions to culture, art, technology and humanity. It sounds like you guys are having some half-decent reforms over there and I wish you the best of luck =D
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willyumtx
User: willyumtx
Date: 2011-07-03 07:16 (UTC)
Subject: (no subject)
Here's an article about a shortage of doctors.

http://www.slate.com/id/2297780/

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