[cancer] Healthcare Weirdness

A decent chunk of my free time yesterday was consumed in pursuing insurance paperwork. The tangle between deductibles, out of pockets and co-insurance is deep and strange. Deeper and stranger still is the relationship between billers, billing codes and insurance carriers. Meanwhile, my time as the patient is spent playing telephone, literally and figuratively, between the hospital and my insurance company.

First of all, I have to meet my deductible. After my deductible, I have to meet my co-insurance target of 10% of allowed billing per procedure. That runs up to my out-of-pocket expense limit, except, of course, for those things which do not count toward my out-of-pocket expense limit.

Clear so far?

Then there was the problem of two of Mother of the Child’s bills. For preventative care. Which is supposed to be covered for the full amount, not applying to the deductible, co-insurance, or out-of-pocket expense limit. Except when it’s not covered. Because, say, MotC saw a resident instead of a staff physician. (We get our healthcare from a major teaching hospital with associated clinics.)

It turns out that when you see a staff physician, the billing code the insurance company receives is associated with that doctor’s Tax ID number, and is processed as a consultation with a physician. When you see a resident, the billing code the insurance company sees is a clinic services code, because residents don’t yet have Tax ID numbers, and so it is processed as a clinic service.

Physician consultations for preventative care are covered in full. Clinic services are subject to deductible, co-insurance, and out-of-pocket expense requirements. The net result is that I or MotC or [info]the_child can see a fully accredited staff physician for no cost to us whatsoever, or we can see a resident — ie, a brand new doctor still in training — and pay about $115 for the privilege of being seen by a far less experienced doctor.

All because of billing codes.

What? The? Fuck?

The response of the hospital billing department? “Well, yes, that’s how it works. In the future you’ll need to be prepared to pay the deductible amount for seeing a resident.”

Me: “So what you’re saying is if I don’t want to spend $115, I need to insist on a staff physician appointment.”

Hospital billing department: “Well, yes.”

Me: “That is some really screwed up customer service.” (Not to mention some screwed up physician training priorities.)

Hospital billing department: “That’s how it works, sir.”

Nope, the healthcare financing system in this country doesn’t need any fixing whatsoever. Nosirreebob. Only a Socialist could think there was anything wrong with this.

4 thoughts on “[cancer] Healthcare Weirdness

  1. Donnie says:

    I run a healthcare billing company and I can tell you that you don’t know the half of how screwed up the insurance companies are.

    They remain at least 30% evil, but they are 70% stupid.

    You are being charged because the resident is considered “out of network.” Because residents don’t have NPIs (National Provider ID), they can’t participate in a network. Hence, some or all of the charges will be billed to you.

    I tell you this as a warning because of your upcoming surgery. Talk to your surgeon and ask if he/she will be using an assistant surgeon. If so (likely), see if they will bill for that surgeon (oddly many hospital systems do not for residents, PAs, etc in assisted surgery). If they don’t bill for assisted surgeons, you’re fine. If they are going to bill, try to make sure the assistant is an in-network physician.

    If you have problems with that, let me know. I can get one of my billing specialists to look into it. Chances are that you will not be affected by this (because most teaching hospitals don’t bill for 1st assistant surgeons), so don’t sweat it.

  2. Donnie says:

    ok, maybe I’m 70% stupid, too. If I didn’t want you to sweat it, I shouldn’t have said anything. But seriously, don’t sweat it. Delete both these comments and have a nice day.

  3. mmmmbobo says:

    I have a Masters degree in this stuff, and am familiar with the hospital you describe. I went through a period where I needed a Significant Amount of Health Care, and I still couldn’t make any kind of sense of my bills either. Kudos to you for trying.

  4. Rachel McGonagill says:

    Well, at least you have Health Insurance, right? (silver lining, etc. . . . 🙂

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