So I want to make an appoint with my PCP to discuss two issues. They explained to me over the phone that if they discuss two issues, they have to charge me for two appointments.
Fine. I made two appointments on different days. I’m retired and my insurance covers it. Same cost to me. Of course, it costs them twice as much.
They charge you for two appointments in one? How does that work?
They charge for each issue. But diagnosis happen are more expensive appointments.
No idea. That’s what they told me over the phone. My former healthcare provider got bought out by Optum, which is owned by the nice people over at UnitedHealth. So I don’t know how the new system works.
I had my Annual Medicare Wellness Visit the week before I picked up my Tesla. I mentioned that I needed my right leg taken care of. The PA said that Medicare doesn’t allow her to discussion anything else during a “Wellness Visit”, and that Medicare doesn’t allow two visits with the same practitioner on the same day. I’d have to come back tomorrow (or a later date) to address the leg.
I agree. I don’t see why the insurance company would want to pay for the second visit, unless the hope is that by making you jump through the additional hoop, you’ll decide against the 2nd visit and ultimately save them that expense.
Long phone wait times to schedule health care is a favorite insurance company cost saving technique.
intercst
Now, I believe that I"ve mentioned before that this “insurance doesn’t allow me to…” hogwash is exactly that. That multiple different procedures codes won’t be reimbursed separately if performed on the same day, or that Medicare’s objective with Wellness visits appear not to encourage discussion of specific symptoms, is an example of the providers themselves being compliant with the third party payer’s dictates.
It was amazing to me that Medicare’s Wellness visits do not include use of a stethoscope and are not intended to resemble an annual physical. I found this out during discussions about the very topic a few doctor visits back with our PCP. How ridiculous!! Fortunately, the folk at our primary care practice think so too.
This is something of an inevitable development as the older practitioners are retiring and the younger crowd take their place (kids who don’t know any better)…and patients who don’t know any better, either! A doctor’s visit isn’t supposed to be a pro forma chit chat that falls within the remit of an insurance company reimbursement…but rather an interview designed to arrive at a diagnosis. Patients themselves aren’t likely to know if two or more separate issues are part of a constellation of signs and symptoms of something elusive (and serious) or that a potentially life threatening cardiac issue is developing and worsening… initially with no other symptoms than a change in heart sounds that could be picked up by simple auscultation.
P.S…I don’t recall ever getting reimbursed for, say, use of local anaesthetic, infection control procedures (including multiple changes of gloves during a long or messy procedure) or the varied trial and error exercises designed to identify exactly where (or sometimes if) patients had toothache. Manifestly, I did all the above and more routinely.
Ive heard of this too. Tbf i almost never go to a pcp so i dont know where this comes from. In my practice im almost always seeing ppl with multiple complaints and its a pain in the rear to make them come back again when theyre already here talking to me. Its another day off from work for them plus childcare or arranging transport for the older folks. It clogs up my clinic schedule making new pts wait longer to be seen. And its twice the documentation.
So i almost always just address all the issues within the scope of my care (hiatal hernia workup, screening colonoscopy, melonama bx, sebaceous cyst, shoulder pain), and make the appropriate referrals where not (ill refill hypertension meds so you dont run out but you need to see your cardiologist in the next month).
And the billing is done by time (the longer you spend with a patient thw higher rvu code you apply), so i dont know where this push to only see one condition comes from. You can also bill by complexity if you dont want to record time (our emr records how long we’re in the chart or in the room with the patient). But even with complexity, the more issues you address the higher your reimbursement.
My only thought is that thier higher ups (management) must be mandating that they see X patients a day
The couple of times that I did a Medicare “Wellness Visit” the medical professional assigned wasn’t my PCP and would have been incompetent to discuss any actual medical issues.
Wendy
@VeeEnn the topic here is the Medicare “Wellness Visit” which is not designed to diagnose or treat any specific medical issue but rather to discuss general lifestyle issues for health maintenance.
I know as much about these issues as I need to so I no longer bother with a “Wellness Visit.” If a patient so much as mentions an actual medical problem (such as @intercst’s leg) the visit is no longer a “Wellness Visit” and is billed as a medical visit.
Wendy
I see the doc every couple years for that “wellness” thing. He checks my vitals and orders bloodwork. As I told the doc, I don’t want anything sneaking up on me.
Steve
The point is, though, that the wellness visit isn’t automatically foisted off on a PA at every practice and, depending upon state licensing requirements, diagnostics are certainly considered to be within a PA’s scope of practice…with PAs and their representatives pushing for ever more increased autonomy.
What’s really at issue here is a healthcare provider (MD/DO/PA/NP) with decision-making capabilities basically allowing their clinical judgment to be guided by non clinical, third party payer dictates. @intercst reported himself that his provider admitted as much to him when she allegedly claimed that she wouldn’t have been able to make such a timely referral if Medicare Advantage had been involved. Stating/implying that she would’ve been somehow compelled to provide treatment that she felt was likely to be ineffective. I have a shrewd idea that this would be an indefensible malpractice case if a patient unwittingly found themselves on the receiving end of such care and suffered avoidable injury …or further complications…because of this. “The insurance company made me do it” would not pass muster with a jury, I fancy. Healthcare providers are supposed to be exercising clinical judgement and, if disease states worsen unchecked whilst on their watch, there ought to be some accountability for such supervised neglect.
Exactly. As step forward to being proactive…or, to look at it another way, a step backwards towards intervention at an earlier stage on the continuum from healthy homeostasis to disease. A distinct possibility…especially in, say, various iterations of ASCVD.
One of the reasons I bang on about using available tools appropriately … “tools” meaning so called advanced testing when lipid profiles raise a Red Flag, use of a stethoscope, etc etc. To me there’s at least as much need for this vigilance in “wellness” visits, annual physicals or whatever moniker is used to describe those visits to a doctor’s office that are seemingly in a healthy person when the individual receiving a clean bill of health doesn’t realize the caveat “as far as I bothered to check” is in operation.
I agree that healthcare are supposed to be exercising clinical judgement. On the other hand, they have lots of experience with insurance companies and patients.
It behooves every patient to monitor and follow up their own health even if they are healthy. (Cue @steve203 .)
If a patient is aware of a problem it behooves them to research it thoroughly and take action. The doctor has thousands of patients but I only have one ME.
My family history includes 8 women on my mother’s side (including my great-grandmother, my grandmother and two of her sisters and their daughters) who had breast cancer.
I kept up with the research and learned that dense breast tissue can hide a tumor from X-rays in a mammogram. I had very dense, very large breasts.
When my 3-D mammogram detected 4 pinhead-sized white dots (calcifications) in a row I requested an MRI (the gold standard for sensitivity and specificity). I told the radiologist that I would pay out of my own pocket in cash. I had insurance but I didn’t want to fight with them.
The MRI detected bilateral invasive ductal carcinoma in 2013. Each was 5 mm – at the limit of detection of MRI which is notorious for false positives. I waited a year and they grew to 8 mm. In March 2015 I had bilateral mastectomy. The cancers were Stage 1 so I didn’t need chemotherapy. There is no way that these tiny tumors would have been detected by palpation or mammography buried deep inside the great mass of dense tissue. (Surgeon removed 3 kg.)
Knowledge, assertiveness, money…all are needed in the event of a serious health challenge.
Wendy
As I’ve mentioned before, my current PCP’s take is a little more congruent with mine than yours WRT what should be expected of a physician at a non problem focused vist (a cumbersome way of describing physicals with no complaints) She actually admitted to surprise after ordering the extra lab work that I requested when we first met (based upon my appearance of rude good health and, by inference, healthy lifestyle choices) and the results of the CAC scan.
The discussion of stethoscope usage in a patient’s visit came up as dh was explaining the series of events that led to his bio-Bentall procedure to the scribe…and the exquisite timing that caught it. He’d had an insurance physical about a month before…no murmer. He’d actually listened about 10 days before the appointment as he gave his own stethoscope earpieces a clean out and checked to see if he’d done abgood job. Nothing telltale. Had the physician we saw on that wellness visit failed to use a stethoscope (this was before our current PCP joined the practice.) I would’ve been a widow less than a week later, in all probability.
No. She would make the referral. She was just warning me that Medicare Advantage would not approve it and tell her to have the patient exercise and elevate the leg for a month or two in the hopes it might get better without the expense of seeing a vascular specialist.
You know, the stuff I’d already been doing for the past 25 years.
intercst
I love www.ergo-log.com
https://ergo-log.com/mushrooms-green-tea-breast-cancer.html
and for all the studies:
Well this is a different version from your first telling (I don’t post so frequently and on that many topics that it’s hard to scroll back and check whether I have False Memory Syndrome).
Either way, it’s an example of a healthcare provider demonstrating that they’ve ceased to become the patient’s fiduciary and is allowing their own clinical judgement to be influenced by a third party. I think it happens very frequently …and usually unwittingly, I’d imagine…when dealing with any third party payer system. Considering that your situation is so unusual, the PA surely couldn’t have seen so many similar cases to have had the experience of such a denial…if she had, and were willing to advocate on a patient’s behalf, that is.
Maybe a PA doesn’t have the same clout with an insurance company in such cases? It’s a fun sport, I guess, to bellyache about a faceless insurance company/third party payer holding us to ransom. It’s sometimes worth pondering how much is due to the individual sitting across a desk from us (our chosen healthcare provider?) and giving out poor advice, for whatever reason.
Not at all.
When I first saw the PA with the complaint of my right foot swelling up, she wrote up the referral for “intermittent claudication”. Then she asked me if “I had a “Tier One Plan”?”, which I assume refers to the quality of my Medicare Advantage insurer. I told her that I’m on regular Medicare and don’t need “prior authorization” to see a specialist. Then she said, “That’s great, I was afraid we’d have to do a month or two of doing something ineffective before sending you to the vascular specialist.” So she wasn’t changing her clinical judgement, merely informing me that with the wrong insurance company, I’d likely have to jump through some additional hoops before getting the referral approved.
Now for the other part of the story.
When I got the bill for seeing the PA, I found out that the local ZoomCare franchise is owned by the healthcare conglomerate that bought out my previous Primary Care Clinic and tossed me off the patient book because I wouldn’t agree to switch to Medicare Advantage. Specialists who are employed by the healthcare conglomerate won’t see you if you have regular Medicare, but non-employee doctors might.
When I told the PA that I had regular Medicare, she looked confused about where to refer me (but she didn’t disclose that her employer wouldn’t accept a referral from a traditional Medicare patient), finally I told her “To just send the referral across the river to Portland Hospital. I already get most of my health care done over there.”
When I got home I looked at the documentation on the referral and it appeared that the patient was responsible for beating the bushes to find a doctor that would accept the referral, then call ZoomCare back and tell them where to fax it. I immediately called ZoomCare back and asked if they sent the referral to Portland Hospital, and they said they did because that’s what I told them.
So the newly established ZoomCare franchise (it was a Subway Sandwich shop up until a few months ago) is a front that allows the Big Medicine conglomerate to get reimbursements from traditional Medicare patients without actually referring them to a specialist for additional care – you’re on your own for that.
intercst