". . . little shall I grace my cause

In speaking for myself. Yet, by your gracious patience,

I will a round unvarnish'd tale deliver . . ."

(William Shakespeare's Othello, I.iii.88-90)

Wednesday, March 27, 2013

Health Care Idiocy

The week after Christmas my youngest child developed an eye infection. When it worsened after a few days we called the doctor and followed the recommendations for home care. When after a few more days there was no improvement but rather a worrisome acceleration of redness and swelling, we called the doctor again. The answer came back: we are booked and can't see you today; you should go to urgent care.

So that's what we did. The urgent care physician diagnosed cellulitis and sent us home with antibiotics. There was no lab work and no other in-office treatment. Just a prescription and an instruction to call if there wasn't rapid improvement. In a few days there was great improvement. We went on with our lives.

Last month we got the bill. Since our health insurance benefits summary lists a $25 copay for either a physician office or urgent care visit with everything else being paid at 100%, we were surprised to see a balance due of $169. I called the insurance company and was initially encouraged that maybe there had been a mistake since the representative on the phone noted that there were two charges for the visit and speculated that maybe one was a duplicate. A follow-up call several days later, however, provided a different explanation. There were in fact two charges: one for $325 for "immediate care" and one for $247 for "professional fees." Per our coverage we are responsible for a $25 copay on the immediate care charge. But after allowing for the preferred provider adjustment on the "professional fees" charge, there is a balance due of $144. That has been applied to our deductible, so the facility is now billing us for it. I argued with the insurance representative to no avail. "But our plan says urgent care is paid at '100% except $25 copay per visit.'" The answer came back: "We can't control how the facility decides to bill. They submitted two charges, a care charge and a facility charge. You will have to take it up with them."

When I go to the doctor I pay a $25 copay. That covers the care and the building in which the care occurs. Why is urgent care different? And why does "100% except $25 copay per visit" not mean "100% except $25 copay per visit"?

Here's what really burns. We thought that by going to urgent care we were doing the responsible thing, saving the health care system unnecessary cost. But guess what? If we had gone to the Emergency Room instead we would have had only a $100 copay. I guess next time we'll just skip urgent care and go straight to the ER.

Something is seriously broken.


Eleanor said...

I've dealt with this several times. I would call the Urgent Care and sweetly and firmly as possible and get them to change the billing. (You'll talk to the billing department.) Remember, you are a stay at home mom, and you will be taking up the accountant's valuable time--you can be making dinner while you negotiate. :)

Their deal with your insurance company is that you pay $25 to see them and they get what they can out of the insurance company. Read your plan very carefully, but my guess is that you can make them re-bill the insurance correctly. Unfortunately, you are not alone in this inconvenience.

Susan said...

Are you SURE about the $100 copay for ER? One time we ended up in ER, and had not only the $100 copay, but also the physician fees and the radiology fees. Most of the time you walk into a hospital, there will be multiple charges: the building, the doctor, the prescriptions, the lab tests, and any imaging tests (X-rays, CT scan, etc).

inga said...

Here in DK, we pay no copay or any fees. It is all covered by the system. Great to know we do not have to worry about the cost of anything except medicines (under 400 USD per year)

Cheryl said...

Thanks, Eleanor. I was planning on doing that. We have not paid the bill and don't intend to.

Susan, it very clearly says in the summary of benefits that an ER visit is a "$100 copay per visit" unless the patient is admitted, in which case the copay is $0. I would take the words "per visit" to include the ER doctor's examination. Maybe I'm wrong on that. We haven't been to the ER in a long time and I can't remember how it was billed last time. But considering that we had nothing else done as part of the urgent care visit--no labs, no procedures, no shots, etc., I would anticipate no other charges if we had gone to the ER. To me a "copay per visit"--whether the visit is to the doctor's office, the urgent care facility, or the ER, should include the basic elements of the exam room and the doctor looking at you. When we go to the doctor it does include those things. If those words mean something else when we go to urgent care or ER they should indicate as much with an asterisk and a footnote: "There may be additional charges for professional services, facility use, etc., etc., etc."

Inga, I do not mind paying according to what we have been told we should expect. I do not want my health care covered by a government-run system because I do not trust the system to make the best decisions for me. What I am frustrated by is the lack of clear communication. I checked our plan and proceeded according to what I understood it to say, but now I have discovered it apparently did not mean what I thought it meant