My parents recently visited a new primary care physician. My father was shocked to see the bill (to the insurance company) was $283.00 for a simple office visit. I explained to him a little about how billing works and where the charges come from. Maybe it would be helpful to others to demystify the office visit charge.
Most office visit charges are based on 3 main factors - 1) the type of visit (office visit, physical exam, or consult visit); 2) whether you are a new patient or an "established" patient to that clinic; and 3) the "level of service" or how much the doctor does during the visit.
The first two are pretty self-explanatory but the third confuses even the most seasoned physician. Level of service is determined by how much history a doctor gathers (asking about why you are coming in, other symptoms you are having, your past medical history, medications you are taking, whether you smoke or drink, etc), how extensive of an exam the doctor performs (listens to heart and lungs only or does a head-to-toe exam); and finally how complex the medical issues are (simple cold versus a complex patient with multiple serious medical problems). Visits can be charged at anywhere from a level 1 to a level 5 (except for physicals which are a "flat" fee).
Level 1 - this is rarely billed by a physician, but may be billed by a nurse who checks a TB test result on a patient's arm, for example.
Level 2 - very straightforward type of visit, for example, checking a rash in an otherwise uncomplicated patient with no other concerns.
Level 3 - most common type of visit - fairly straightforward visit for a cold, sinus infection, sprained ankle, or a visit with a complex patient for a single issue that is stable and needs no change in medications.
Level 4 - most patients with uncontrolled diabetes, multiple medical problems, or presenting with a serious concern (like chest pain) will warrant a level 4 visit.
Level 5 - I rarely use this code because it involves a high level of care and a serious medical problem. One example of a level 5 visit would be a child with uncontrolled type 1 diabetes who presented having a hypoglycemic (low blood sugar) reaction requiring me to coordinate specialty level care on an urgent basis.
This is a very general overview. Visits can also be billed based on time. If a doctor spends more than half of the visit counseling a patient or coordinating care, the doctor can bill for the corresponding level visit (level 3 is 15 minutes, level 4 is 25 minutes, level 5 is 45 minutes). I typically use this type of billing when I am diagnosing someone with diabetes. I spend almost the whole visit counseling about diet, exercise, medications, tests, complications, etc. and very little time examining the patient or asking about other symptoms.
So, you can get a sense of why health care billing is so complicated and difficult to figure out. My next post will be on "RVUs", the basis for assigning a "value" to each and every service provided to patients.
Wednesday, July 30, 2008
Friday, July 25, 2008
What my patients mean to me
The best part about being a family doc is definitely my patients. I continue to be amazed when one of my patients returns to me for a visit after I have sent them off to the heart specialist, bone specialist, or blood specialist for a condition that I do not have the expertise to treat. Inevitably, after I ask them what the specialist recommended, they will tell me the prescribed treatment and say something like "But I told him, doc, that I wouldn't do anything until I talked to you." Flattering as this is, I remind the patient that I sent him or her to the specialist specifically for a recommendation that I wasn't able to make. However, it demonstrates the trust that my patients have in me and I hope that trust is a manifestation of the care they sense I have for them.
My patients are much more to me than a sore throat, diabetes, or a broken foot. Maybe it is because a family doctor has to focus on the whole person - there is no "part" we don't take care of - that I still look at my patients as whole people. This allows me to not get too upset when my patient with heart disease decides to stop taking his cholesterol medication. Yes, cholesterol lowering is important, but I can understand that the side effects from this medication make his quality of life so poor that it's just not worth it. This "holistic" approach satisfies the humanity of my profession, allowing me to become much more than a technician or an expert. I am a care provider in every sense.
Of course, that is not to say that I adore each of my patients. Many are challenging causing me to groan inwardly when I see them on my schedule. I never want to lose sight, though, of the individual person who has a completely unique make up, set of circumstances, and hopes and dreams for himself.
Of course, that is not to say that I adore each of my patients. Many are challenging causing me to groan inwardly when I see them on my schedule. I never want to lose sight, though, of the individual person who has a completely unique make up, set of circumstances, and hopes and dreams for himself.
Wednesday, July 23, 2008
What is a family doctor?
I remember going to a "family doctor" growing up. He was actually a general practitioner with no formal training in family medicine. But, he embodied many of the characteristics I try to display in my family medicine practice.
He lived in the community where he practiced. I went to school with his kids. I worked in his office as a summer job. You would see him at the grocery store or church. He had immediate legitimacy because he knew where you came from.
He was available. If I stepped on a nail and needed a tetanus shot, my mom could just take me over right away. I wasn't turned away and sent to the urgent care clinic or the emergency room. He was my doctor and just provided what I needed.
He practiced a lot of "social medicine". Prescriptions were often given for social maladies - domestic violence, substance use, poverty, illiteracy. These are the true illnesses that patients bring to their doctors so often.
He was compassionate. He frequently "no-charged" patients who were facing financial difficulties. It drove his office manager wild to lose the income, but he was a true softie, and cared more for his patients than his checkbook.
He also displayed qualities I actively avoid.
He was always busy and always late. He routinely scheduled 4 patients every 15 minutes. I could not be happy doctoring that many patients that quickly. As much as possible, I try to schedule the actual time I will need with patients and stay on time with my appointments.
He cut some insurance corners. I remember one occasion when he charged a patient for a visit (she was insured through the state medicaid system) without actually having seen her. He did talk to her on the phone and provided a prescription, but did not see her face-to-face for a visit, which is usually required to charge for an office visit. I can now appreciate the temptation to do that since I sometimes can spend 1 or 2 hours in a day taking care of a patient without seeing that patient in the office. But, I play it straight with the insurance rules and regulations.
He was not home much. He worked long hours, burning the candle long after the clinic closed. I love my family and enjoy being with them. When my day is done, it is done. When I am on call, I perform my responsibilities but don't spend extra time doing non-essential things.
He did not pay attention to the business aspect of medicine. One summer when I was working in his office, I added up his outstanding bills. The total was in excess of $40,000.00. Wow. That is a lot of money. I try to attend to the balance between cost and income so that I am practicing in a fiscally responsible fashion. That said, the financial aspects of medicine in the U.S. are nonsensical and atrociously designed.
As a family doctor, I take care of the whole family. This both means that I frequently have entire families as my patients, but also that I "treat" the emotional and psychological aspects of a patient's illness in all of his or her family members.
I take care of patients from birth (sometimes even in utero) until death. That is really cool!
I take care of patients wherever they are - home, hospital, jail, nursing home, or my office.
I provide the majority of health care - labs, chronic disease management, procedures, acute care, form completion, patient education, counseling, and hand-holding.
Being a family doctor is the most fun kind of doctor you can be.
He lived in the community where he practiced. I went to school with his kids. I worked in his office as a summer job. You would see him at the grocery store or church. He had immediate legitimacy because he knew where you came from.
He was available. If I stepped on a nail and needed a tetanus shot, my mom could just take me over right away. I wasn't turned away and sent to the urgent care clinic or the emergency room. He was my doctor and just provided what I needed.
He practiced a lot of "social medicine". Prescriptions were often given for social maladies - domestic violence, substance use, poverty, illiteracy. These are the true illnesses that patients bring to their doctors so often.
He was compassionate. He frequently "no-charged" patients who were facing financial difficulties. It drove his office manager wild to lose the income, but he was a true softie, and cared more for his patients than his checkbook.
He also displayed qualities I actively avoid.
He was always busy and always late. He routinely scheduled 4 patients every 15 minutes. I could not be happy doctoring that many patients that quickly. As much as possible, I try to schedule the actual time I will need with patients and stay on time with my appointments.
He cut some insurance corners. I remember one occasion when he charged a patient for a visit (she was insured through the state medicaid system) without actually having seen her. He did talk to her on the phone and provided a prescription, but did not see her face-to-face for a visit, which is usually required to charge for an office visit. I can now appreciate the temptation to do that since I sometimes can spend 1 or 2 hours in a day taking care of a patient without seeing that patient in the office. But, I play it straight with the insurance rules and regulations.
He was not home much. He worked long hours, burning the candle long after the clinic closed. I love my family and enjoy being with them. When my day is done, it is done. When I am on call, I perform my responsibilities but don't spend extra time doing non-essential things.
He did not pay attention to the business aspect of medicine. One summer when I was working in his office, I added up his outstanding bills. The total was in excess of $40,000.00. Wow. That is a lot of money. I try to attend to the balance between cost and income so that I am practicing in a fiscally responsible fashion. That said, the financial aspects of medicine in the U.S. are nonsensical and atrociously designed.
As a family doctor, I take care of the whole family. This both means that I frequently have entire families as my patients, but also that I "treat" the emotional and psychological aspects of a patient's illness in all of his or her family members.
I take care of patients from birth (sometimes even in utero) until death. That is really cool!
I take care of patients wherever they are - home, hospital, jail, nursing home, or my office.
I provide the majority of health care - labs, chronic disease management, procedures, acute care, form completion, patient education, counseling, and hand-holding.
Being a family doctor is the most fun kind of doctor you can be.
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