Diagnosis coding is for the insurance companies. It helps them know what to expect in the way of cost for your treatment. It also helps them to build a case for not paying for the treatment and/or dropping you from their rolls.
The medical profession uses the diagnosis codes to pad their fees to pay for their high cost overhead. The most expensive overhead item is the large number of personal working to extract money from the insurance companies.
I have a friend that works on the insurance side of the business. She said, “When we receive the first claim we note it in the computer and throw it away. When we get a call asking for payment, we say I never receive a claim for that office visit. Often they will do the same to the second claim as they did to the first. Then a certified letter is sent needing a signature…. So now they can’t say they didn’t receive it. So the insurance company asks for more information concerning the office visit. Please write a detailed report. They stall for as long as they can. They generally end up paying the medical professionals. The professionals know not to give up. They do try to discourage the insured person if they send in the claim themselves. The insurance companies will stall as long as they can in the hope that you will forget or get discouraged.
The way that the doctors pad their fees: Say you go to the doctor for a sore throat. You have looked in your mouth and have seen the white pus pockets. You don’t have a cough or post nasal drip. I would rank it with a 98% assurance that you have strep throat. What would the doctor have to do to know that you have strep throat? Listen to your history (no cough or post nasal drip) and look down your throat (white pus pockets). He too should be 98% sure that you have strep and write a prescription for you.
What does happen at the doctor office: They weight you, make note on the insurance form, they take your blood pressure, make note on the insurance form, they ask you question to search for other maladies’ you may have…. Such as depression, make note on the insurance form. Each thing that they do allow them to honestly mark down that you had a “complex” office visit, so they can charge the insurance companies more $$$. Taking your temperature, looking in your ears and nose would make sense to see if the bacteria are attacking other parts. But I wouldn’t want the insurance company to know if I am overweight and have high blood pressure unless I am seeing the doctor for that reason.
A rapid strep test, does it need to be done? No, not if the strep is classic/obvious. A strep culture, does that need to be done? Not usually. That is generally done to find out which specific anti-biotic will kill the strep. Some strep can only be killed by a certain anti-biotic. Most can be killed with a broad spectrum anti-biotic. So if you don’t do the culture, it is possible that you won’t get better and have to request a different anti-biotic. The next anti-biotic won’t be a sure thing. The problem with strep is that it can lead to a much more dangerous illness. So the doctor wants to be sure that he has done all that he can to diagnose you correctly and give you the best treatment for your strep.
All of the padded fees and perhaps unnecessary test might not matter to you, if you only have to make a co-pay payment. But it can really bite your wallet if you haven’t met your deductible yet. Or if you don’t have insurance. What you can do is take charge of your visit. Tell them for price reasons you don’t want to be weighed or have your blood pressure taken. You could say that you are willing to try a couple broad spectrum anti-biotic; if that doesn’t work you will come back for a strep culture. That will be costly to have a second office visit and the doctor may not be willing to treat you if you don’t take all his advice. So you have to weigh to pros and cons. This is one of the freedoms we have in the country.
Back to the padding of fees and tests. That is why your insurance premium is so high. But the doctors truly need that money to pay the staff that works to get the money from the insurance company. Catch -22.
If you are uninsured or underinsured: The doctors of cannot charge you a different price than what is charged to the insurance companies. That would be insurance fraud. But the insurance company has a contract with each doctor stating what percentage the insurance company will pay. So you get charged $100.00. You have to pay all if it. The insurance company is charged $100.00; their contract says they only have to pay 80% of the bill, so they pay $80.00.
There are very few options to reduce your bill. As previously stated: be in charge of your office visit say, No, if something seems unnecessary. Perhaps they will give you a good reason why it is necessary and you can change your answer or not. Another method is to pay cash on the spot at the end of your visit. Usually you can get a cash discount anywhere from 10% to 50%. Call ahead and find the person that can authorize a cash discount, usually in billing, get their discount figure and GET THEIR NAME, so the front desk can verify your claim. You can ask the person you spoke with to tell the cashier, but they are very busy people and that might not happen. Last method is finding a “direct pay” doctor for every day issues and use medical tourism for big ticket items. Use the internet to find these wonderful clinics and hospitals. If the internet does help, talk to pharmacists. We do have a medical tourism hospital in the U.S. of A. And there are direct pay docs that don’t take any insurance so that can and often do charge considerably less.
Next Hipaa: they say it is to protect your privacy, that if you are across the country, away from your usual doctor, and you are in a serious accident, the hospital can pull up your charts and learn information that may save your life. That is true. Or you could wear a medical bracelet or “dog tags” that say what you are allergic to and what medicine you are taking to treat health issues.
The problem with Hipaa is that it doesn’t protect your privacy. A prospective employer can pull up your information and see that the nurses that questioned you think you are depressed or any other information that you would rather not sure with others unless that get your consent. For a medical office to give out that information, they have to have your signature to share that information. You can give them permission to see all your medical records or you can limit what information is shared. Hipaa does need your permission. The doctor has to send your information to Hipaa, if he does any electronic billing. Only the “country doctor” clause can relieve the doctor of share your information. Often direct pay doctors fit inside the country doctor clause.
Now all of the above is the medical gospel according to what I know. Insurance companies are not evil, they have to pay their employees salaries. Perhaps now with electronic billing they no longer say they didn’t receive the claim. My information may be out of date. Most doctors got into the field because they like people in general and what to help them. They would like to do things differently, but they are not their own boss, they work for the board of directors and shareholders, and they want to keep their jobs. Also that don’t know how to do a direct pay practice and what if it doesn’t work.
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