Author: Foot Doc
Date: 8/19/2007 4:24 pm PDT
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Billing in medicine should be the individual decision of the provider, just as it is in any business. But as many patients have insurance coverage, and more often than not the doctor has signed a contract with the insurance company to limit his/her fees to their fee schedules which also determines co-pays, fees and billing have now become more of the insurer's decision than anyone else's. When a non-insured patient is charged more than an insurer would pay for the same care, it is because the doctor is not required to artificially discount his/her fee. That may sound unfair, but it is equally unfair that most time the insurance company determines the fee and it is always less than what the doctor feels is appropriate. When he/she can get the full fee, he/she generally does so. Also, as most insurance coverage is provided as a benefit from employers, the employer must consider the range of benefits and their cost to him/her when purchasing insurance for employees. In the old days, insurance was a matter only between the patient and the insurance company, and the doctor would generally accept assignment of benefits so that the fee would come directly to him/her. Sometimes the price for this was that the doctor had to allow the insurer make fee decisions. But over the last 40 years or so these indemnity policies have been largely transitions into defined benefit policies, and generally, for gaining the ability to service the insurer's customers and receive direct payment, the doctor is forced to sign an agreement with the insurer to allow them to make most of the financial decisions. So now, fees are frequently a three-party situation.
Billing is done by standard diagnostic and procedural codes, and although there is some flexibility related to the level, extent and skill of care, most time the doctor has to force whatever is done into the closest code. This often presents problems, in that the fees paid for each code differ greatly between insurers and are not necessarily in line with the degree of difficulty. As an example, a simple injection often is awarded an unrealistically excessive fee, while a real surgical procedure may be underpaid. So when you see a relatively simple procedure paid very well, you can be assured that the doctor also accepts less than a fair fee for some other perhaps more difficult procedure.
In general, if a cast needs to be re-applied because of the negligence or lack of adherence of instructions by the patient, he/she should accrue an additional charge which may or may not (probably not) be covered by insurance. Diagnoses and procedures are linked, so when a procedure is performed for a diagnosis for which it is not generally called, there can be problems in receiving insurance compensation. |
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