BrianB
Recycles dryer sheets
About two weeks ago I did something to my back. I had serious low back pain, and only felt OK if I was sitting in an upright chair or lying flat on my back. DW said, "Go to the Doctor!" Stubborn me said, "It'll get better!"
After 10 days of Ibuprofen with no improvement I finally conceded. I made an appointment, saw the doctor for about 15 minutes, and left with a prescription for a muscle relaxant. Today we got the EOB (Explanation of Benefits) and the bill: $283 for the visit and prescription. Yikes!
DW worked in health insurance for 20+ years and knows the system, so she helped me to understand and I want to pass along the information. Note that this is general info only, but an informed consumer can save money.
Almost all doctors use "CPT Codes" which are standard definitions for illnesses, injuries, and medical problems. The CPT code is usually on the EOB, you just have to look for it. The most common CPT code people see for an office visit is: 992xy.
The "992" indicates a general office visit.
The variable "x" can be either "0" (new patient) or "1" (patient previously seen in that clinic / department / specialty).
The variable "y" can be "1" (minor) or "2" (low to moderate) or "3" (Moderate) or "4" (moderate to severe), or "5" (severe). These refer to the complexity of the case, not the pain level.
A CPT code of 99211 would be the lowest cost office visit for an established patient (about $100 in our HMO), while 99205 would be the highest cost for a new patient (about $360 in our HMO). Quite a difference!
The CPT code is assigned by a clinic employee, not the doctor, but is based on the doctor's notes. There are significant financial incentives for the clinic to "upcode" (use a code for a more severe case) and "miscode" (bill as a new patient when they are not).
In my case the visit was billed as a "99203". It should have been 99211 or 99212 as I have been to that clinic before and my case wasn't complicated. The price difference is more than $100.
We called the clinic and explained the situation. We are still waiting for the clinic to get back to us but DW is confident we will get the bill reduced. We are fortunate that DW understands the system.
Here is a typical insurance industry chart (this one from Optum) showing how the codes should be assigned: https://www.myoptumhealthphysicalhealth.com/Documents/Reimbursement%20Policies/E_M%20QuickReferenceTable.pdf
By the way, my back is really feeling better now!
After 10 days of Ibuprofen with no improvement I finally conceded. I made an appointment, saw the doctor for about 15 minutes, and left with a prescription for a muscle relaxant. Today we got the EOB (Explanation of Benefits) and the bill: $283 for the visit and prescription. Yikes!
DW worked in health insurance for 20+ years and knows the system, so she helped me to understand and I want to pass along the information. Note that this is general info only, but an informed consumer can save money.
Almost all doctors use "CPT Codes" which are standard definitions for illnesses, injuries, and medical problems. The CPT code is usually on the EOB, you just have to look for it. The most common CPT code people see for an office visit is: 992xy.
The "992" indicates a general office visit.
The variable "x" can be either "0" (new patient) or "1" (patient previously seen in that clinic / department / specialty).
The variable "y" can be "1" (minor) or "2" (low to moderate) or "3" (Moderate) or "4" (moderate to severe), or "5" (severe). These refer to the complexity of the case, not the pain level.
A CPT code of 99211 would be the lowest cost office visit for an established patient (about $100 in our HMO), while 99205 would be the highest cost for a new patient (about $360 in our HMO). Quite a difference!
The CPT code is assigned by a clinic employee, not the doctor, but is based on the doctor's notes. There are significant financial incentives for the clinic to "upcode" (use a code for a more severe case) and "miscode" (bill as a new patient when they are not).
In my case the visit was billed as a "99203". It should have been 99211 or 99212 as I have been to that clinic before and my case wasn't complicated. The price difference is more than $100.
We called the clinic and explained the situation. We are still waiting for the clinic to get back to us but DW is confident we will get the bill reduced. We are fortunate that DW understands the system.
Here is a typical insurance industry chart (this one from Optum) showing how the codes should be assigned: https://www.myoptumhealthphysicalhealth.com/Documents/Reimbursement%20Policies/E_M%20QuickReferenceTable.pdf
By the way, my back is really feeling better now!
