Visit codes and other billing details

Ok, my subject line was just a tad sarcastic. But in all seriousness, myself and my staff get questions all the time about office codes, procedure codes, billing insurance, and more, so I thought I'd break down a couple of the most common myths, misconceptions, and tricks I've learned over my 10+ years of billing insurance in a medical practice.
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​first up, know your deductibles

"Compare Health Insurance" by sinclair.sharon28 is licensed under CC BY 2.0.

We're nearly midway through the year (I still can't believe it) so most folks who have standard deductibles, and get regular medical care have already met them, so now that emotions are not at the fever pitch they always are come January, let's talk about them a little bit.

My office, like most out there, tries to get the most accurate basic insurance coverage information that we can for all new patients. For many reasons, sometimes that doesn't quite work out.
Here are a few top reasons why we might not have accurate information:

• The insurance rep on the phone just gave us straight up incorrect information (happens more commonly than you might think)
  
• Your HR department decided to switch plans on you
  
• The appointment was booked with so little advance notice that my staff was not able to call to verify coverage at all
  
• There is a small error on our end (even one digit of a member ID number for example), and staff couldn't reach you in time so was unable to determine your insurance coverage
  

These are not excuses, just explanations. As patients (I get regular medical care too, of course), it is our responsibility to be familiar with our insurance coverage details. If you don't think you have any deductible, and my office or another tells you your insurance company says you have a $2,000 deductible.... well... there's a pretty big disconnect somewhere along the line.

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choosing when to use insurance based on deductibles

I'll use myself as an example. I'm looking to get a new insurance plan in a few months. If I get one with a $1,000 deductible, I'll just start using my insurance right away. I know I'll get bills for my care coming my way, saying that the cost of those visits was applied to the deductible. I'll be responsible for paying them in their entirety until that deductible is met.

If I choose a plan with a $5,000 deductible however, that's pretty high. I might not actually meet that deductible before its annual renewal, and I'd be paying those higher "total billed amounts" the whole time. So what I will be doing, if I choose a plan with a higher deductible, is paying for my visits directly to the providers I see. That way I can get the "Time of Service" self-pay discount (usually around 25% off). I can then send those itemized invoice receipts (also called superbills) to my insurance company so they can count towards my deductible in case I do end up meeting the full $5,000 (which would easily happen if I need surgery or other emergency care for example).

I am also deciding what type of Health Savings Account to open up, which either way will pay for such costs as co-pays, medication, and whole office visits that are not billed to insurance.

Sound complicated? It is.
Medical care in this country is stupendously complicated.

If this is all making your head spin, talk to your HR person and discuss what is the right fit for you, based on your insurance plan specifics and your healthcare requirements.

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"Medical bills WITH health insurance." by attercop311 is licensed under CC BY 2.0.

I don't recommend the "let's just bill it and see" approach

How many of you have heard me say, "when it comes to insurance, surprises are generally not a good thing." I say that often for a reason.

The most common reason I see in office for wanting to know your coverage details, is that if a patient has no coverage for visits or a type of injection service, then it is more affordable for them to pay up-front.

Like what I mentioned above, self-pay rates are often about 25% less. The reason for this is as providers contracted with insurance companies, we have to play by many, many rules. However, they let us provide discounts to those who do not bill any insurance for that service because they know how much back end expense there is to billing insurance (reception staff to verify coverage, medical assistants to coordinate pre-authorizations, office billing staff to submit codes, address their incorrect claims, etc, etc, etc).

That being said, the choice to self-pay needs to be made at that office visit. Not months later when someone has found out that what they thought was covered (or never checked to see whether it was covered) is in fact not covered. I'm sure everyone can see how the work was already put in on our end, so the appropriately-named Time of Service discount can't apply later on.

Here's just one sad tale to illustrate the importance of knowing your insurance coverage details. About five years ago a patient asked me to run more extensive labs than would have been my initial workup, requesting a lot of extra allergy and food panel testing.

As many of you know, I take into consideration patient requests. I truly try my best to listen to every patient.

Unfortunately for him, he was not aware that he had a $2,000 deductible for lab coverage, so he was hit with a very large bill.

I do my best to use my past knowledge of running hundreds and hundreds of labs to know what insurance companies often cover (vs. what they often don't), but at the end of the day I hope everyone can see that it's not my job to know my patients' insurance coverage details inside and out.

It's just not possible for me to know everything about everyone's plans.

So, please, please, please familiarize yourself with your insurance plan benefits. And if you are not finding the details you are looking for in your insurance coverage booklet and talking to your HR person, and end up calling your insurance company, please write down the rep's name and call # when you take down those details.

Patients have told me that they were able to get some past services covered, when their insurance was initially denying coverage, because they were able to provide the call # and rep name who assured them it was in fact covered.

Yes, this is ridiculous.
No, we shouldn't have to fight so hard to get the medical care we pay for.
But this is the system that we have at the moment.

"health insurance claim paperwork" by franchiseopportunitiesphotos is licensed under CC BY-SA 2.0.​

I'm going to get even more into visit code weeds for a minute

One recent change, along with all of the above, is updating some of our billing rates on both office visit and procedure codes. For patients who self-pay, some of those have increased, and others have stayed the same.

The reason for this is multifold. For the office visit rates themselves, I will let you in on a little history. My office visit self-pay rates had not increased since I started practice in 2012. But the prices of.. well... everything else all around us has. We had planned on finally increasing our rates in 2020, but you know the end of that story. So we kept our rates stable on every single code until now, and have finally increased some. So for example, a visit that may have had a self-pay rate of around $120 is now around $160.

If you have any questions or concerns, please talk with me. I am open and do my best to address all my patients' needs. And that sometimes means addressing the financial reality as well. If you want to schedule a shorter follow-up visit (less complex, lower visit codes therefore lower rate), please just let me know. We have our standard new patient and follow up times, but in addition I do my best to accommodate every need I can.

For procedure codes (which includes all types of injection visits), again some of those codes have stayed the same, and some have increased slightly.

Most patients will not notice or be affected by these changes, since the changes mostly affect codes that we bill out to insurance anyway (such as trigger point and scar adhesion release injections). Prolotherapy rates are unchanged.

The reason for the injection code rate increase is actually that some of our codes were being billed out all backwards. More complex trigger point injection codes were being billed out to the insurance company at rates lower than the more simple injections. I won't bore you with more details, but that's the reason for that.

If you would like an updated procedure (injection) code rate document, I can share it at any time (email directly or during a visit) as can my staff.

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thank you all who have hung in there through this whole post

I know this wasn't the most exciting email you've ever read, but because insurance is such a huge and tricky topic, I think it's worth diving in every once in a while. I like to think I've learned most of the rules of their game, and try to share that knowledge and experience with my patients.

Next message will be much lighter- I'll be highlighting some of the home care, tools, and resources I share with patients that address joint and muscle pain.

I hope you are staying cool and well hydrated (I am a Naturopathic Doctor after all),
Dr. Angela Cortal

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