When my wife fell on the ice two winters ago, her wrist didn't look as nature intended. She went to her doctor, who advised her to go to the X-ray department in the building. With her wrist still crooked months later, she got a second X-ray from her usual imaging facility so that the orthopedist could compare the two.
The health insurer sent the explanation of benefits (EOB) for each X-ray, which showed how much it cost. Big difference. The EOB for the initial X-ray was $1,200, while the EOB for the second one was $100.
Why was the original billed at Cadillac cost? Her doctor's office is in a building owned by a corporation which also owns area hospitals. When she asked about the difference in price, they told her that the first X-ray was performed at a hospital and therefore billed at a hospital rate. My wife said that seemed strange, since the so-called hospital had no emergency room, no beds for patient admission and wasn't listed on the state's insurance website under its directory of hospitals. The outcome: the corporation offered a refund of $1,100 -- the difference in price between the two X-rays.
Co-pay or not co-pay
As doctors, hospitals and medical facilities, legitimate or otherwise, cope with the Patient Protection and Affordable Care Act, they are looking for new and creative ways to squeeze money out of patients' pockets. Much of it has to do with the way procedures are coded. These are the numbers on the forms submitted to your insurer and to which most people pay no attention. But you should, because your insurance company does.
Routine screenings such as physicals, mammograms, and colonoscopies cannot have co-pays, according to health reform legislation. This provision was intended to promote preventative care in hopes of keeping people from getting sick in the first place rather than spending a fortune to treat them afterward. But this doesn't stop your medical provider from using sneaky methods to get around the rules and demand a $30, $50 or even $200 co-pay for a procedure that's not supposed to have one.
Most patients don't want to cause a scene or are intimidated by white coats, needles and that antiseptic smell, so they pay. Those who have generous medical plans with minimal co-pays, because their employer pays most of it, usually pay. But those who are self-employed or have high-deductible plans should be reluctant to pay because it's your money.
The dreaded colonoscopy
So how do health care providers get away with it? It has to do with that tricky coding I told you about. My wife had a colonoscopy and the surgery center demanded a $200 co-pay. When she refused, she was told that even if she didn't pay now, "You will pay." It wasn't until my wife read her EOB that she figured out why.
If colonoscopies are routine screenings, they require no co-pay. But the outpatient facility she used cleverly coded it as diagnostic rather than as a screening, even though nothing else was done during the procedure. The doctor accurately coded it as a screening, but the anesthesiologist added to the confusion by using still another code.
When my wife had her skin screening with her dermatologist, the provider demanded a $50 co-pay.
"But this is a routine screening," she protested. "What's more routine than a skin screening?"
"Yes," the woman said, smiling. "But I work for a dermatologist. And he's a specialist." Go figure.