Sometimes we doctors need to let off some steam. The
following is a discussion I had with my billing manager, Sandi, about Mr. H. He
called to complain about his bill. My question to you, dear reader, is should I
send this to him or not?
From Sandi:
Hi Dr. Zapf, A patient came into the office today to dispute
his bill. He says he came in and saw you for 2 minutes
to confirm his evaluation from another doctor. We charged for an intermediate
office visit, Blue Cross allowed $87.87 and it all went to his deductible. He
thinks 2 minutes shouldn't equate to $87.87, you know the thought process...
I wanted to e-mail you so I'd keep it fresh in my mind.
Reversing the charge doesn't seem right; it was the only thing billed
that date and he did come to see you. I think people just don't understand what
the doctorin' business is all about. Did he think an office visit was supposed
to be free? Doncha just love these?
My reply:
Dear Mr. H.,
Sandy told me about the questions
you have regarding my bill. I guess if I was in your position I would also have
these questions. But I feel it my duty to explain a few things to you, from my
perspective.
First, regarding the charge, I
billed you the average fee for any doctor for a first visit, it has a code
number of 99203 and it means an “average visit”. We charge $123 for this
average visit. Your insurance company, in this case Blue Cross, approved only
$87.87 of my bill.
You stated that the visit “only
took 2 minutes”. But you know what, even if we only met together for 2 minutes,
there was much more involved than that. It took probably 2 minutes for my front
office person to schedule the appointment; that is if you never called to change
the appointment date (which many people do). When you came to the office it took
at least two minutes to put your paper work into a chart and copy your insurance
information. When the visit was over it took another minute to process the
superbill and another minute to file you chart in the chart system. Your chart
and the papers it contains, by the way, probably costs us about $2.00
considering the purchase and/or copy costs involved. When it came time to bill
your insurance it took at least 2 minutes to enter your information into the
computer and process the claim. I am charged a fee from the company which
electronically processes your claim. Blue Cross, by the way, required us to
submit the claim electronically or they charge us an extra fee to send in a
paper claim. When we get the insurance statement it takes another two minutes to
enter that information into the computer and another 2 minutes a few days later
when we printed out the claim and sent it to your house to collect the amount
owed. When you came in it took another 2 minutes to talk with you and it will
take another 2 minutes every time we have to process your claim if it was not
paid in full with the first billing. In a year or two it will take 2 minutes to
move your file from its current home to long term storage. It will take 2
minutes to record your information in a log file so we know just where your
chart is filed. There is also a fee we are charged to store files and a small
portion of this fee is allocated to you. How many minutes are we up to now?
Maybe they were not all with me but all those 2 minutes of people’s time must be
paid out of your payment. Blue Cross understands that every doctor
incurs these
fees with every new patient and allocates a little extra payment for a new
patient visit.
We set aside 30 minutes of our
time for a first visit. (Sometimes
the visit takes 2 minutes and sometimes the visit takes 90 minutes) That is 30 minutes of my time and at least one back office
person. Since we had no way of knowing that you only needed 2 minutes, we give
you the full 30 minutes. That is better in the long run than to hear you
complain that you needed 30 minutes to explain your problem and were only
scheduled for 2. Can you see this argument “What do you mean you can only see me
for 2 minutes … it takes me longer than that to remove my shoes…?”
I am sorry but $87 for 30 minutes
in a doctor’s office is not much money. Have a plumber come to your house for 30
minutes and what do you pay? (You have probably heard the joke where the plumber
says “Yes, I know, that’s why I switched from being a doctor to
being a plumber”) Without giving
you a litany of the expenses of running a medical office I will tell you that
making $87 every 30 minutes for six hours a day does not make one rich when you
subtract expenses for the offices, employees and malpractice insurance. I am not
complaining and I am not uncomfortable, but it is not an unreasonable amount of
money.
A side
comment about fees. Doctors do not exactly get paid by the hour. They get paid
by the job based on certain guidelines. In this case the job was to give you an
opinion about a procedure. I have 16 years of experience
[more now since this was written in 2002] and 6 years of medical
education for a grand total of 22 years at podiatry after graduating from UCLA
with a master’s degree. You are getting a heck of an opinion for your 2 minutes.
I will argue that my opinion in 2 minutes is better than others you can get for
30 minutes, even if they charged you less. If you are unhappy about my
expertise, please let me know. What would you value more, a 2-minute opinion on
a proposed foot surgery from an expert or a 60 minute opinion from
your cousin, brother-in-law, or
your plumber?
Now to the concept of the
deductible. Blue Cross requires you to pay to some doctor the FIRST $200 or $250
or $500 of expenses every year. Sometimes it is you family doctor, sometimes
your heart doctor and sometimes it is to your foot doctor. But you are required
to pay it to somebody at some time. We will get in trouble with Blue Cross if we
do not collect the deductible. Insurance companies consider it fraud to not
collect deductibles. They figure that the doctor is giving the patient an unfair
incentive to accept a service. This year the medical lottery has you paying the
first $87 to me. It is just my luck that you are healthy. If you were unlucky
enough to need to see two doctors before me this year, then you would have had
to pay your deductible to them. Blue Cross would have written me a check for $87
and we wouldn’t be having this discussion.
As a side note, you do have some
control over the amount of the deductible you have to pay. If you pay more every
month for your insurance premium, you could have a lower deductible. If you pay
them less every month you will have a higher deductible. Do you see the logic
here: you pay them more and me less or them less and me more. Next year when
your enrollment comes around voluntarily agree to pay more per month and you
will have a lower deductible. The three variables that insurance companies use
to determine your rates are the deductible amounts ($100, $200, $500 or $1000),
the amount of your office visit co-payment ($10, $20, $30 or $40) and the
percentage of the total charge they pay (90-10 or 80-20 or 70-30).
If after reading this you still
think I charged too much I will agree to charge you whatever you think is fair.
I will have to “rebill” the insurance company at the lower rate and they will,
in turn, “approve” a lower amount. This will, in turn, reassign a portion of
your deductible to another of your doctor visits. You will still end up paying
for every portion of your deductible, just not to me.
Please call Sandi and let her
know how you want to proceed.
Sincerely,
Michael Zapf, D.P.M.
