Does this medical office practice sound ok to you?

I’m not a doctor but I am a consumer – and a taxpayer.
That does not seem right to me. I’ve never had an experience like that.

This sort of thing is becoming commonplace. My wife went to her cardiologist recently and we started getting charged for all sorts of things. Example: she was charged for education and treatment for smoking. When my wife called to question this, the girl looked into it and found they had discussed smoking during the office visit. According to my wife the conversation went something like:

Doctor: Do you smoke?

Wife: Sometimes.

Doctor: Okay. Don’t smoke too much because it’s bad for you.

Because he mentioned it he can bill for it. And it was something silly like we had to pay $50 for it. The insurance was billed for over $400.

You could call your insurance company to question it, but I doubt you would get anywhere. They don’t care. It is a racket and everyone is getting rich off it except the patient.

Sounds like typical, shady business crap…

Call their billing person and tell her there has been some sort of mistake and hopefully they correct it.

It’s fraud in my opinion.

They maybe could argue charging for a phone visit, but that certainly should not be billed as a full fledged office visit. I don’t know if your condition reasonably needed a medical professional to check on how you were doing, or if it was perfectly reasonable to just prescribe you 30 days of meds with 2 refills (or 5 refills) from the very start and you can call or make an appointment if your condition changes.

I agree with @seawulf575 about insurance not caring about fraud, but it is another route to try if you get nowhere or if you want to make insurance aware not to pay.

I have outright accused a doctor’s office of fraud when they charged my insurance for a visit and I was paying in full for a cosmetic procedure. I didn’t make the accusation until the billing person tried to tell me it was ok what they billed. I first gave them a chance to fix it. I told my insurance, I don’t think they cared. They might have still paid it for all I know. Too stressful to follow up at the time.

No – it doesn’t sound right. And not all doctors do that. Can you ask the pharmacist to call and ask for the renewals? They often will do that. I would also call that doctor’s office and talk to the billing person. They should not be charging you for an office visit for a phone consultation.

I think the rules for phone visits changed with the pandemic, but there are different “levels” for an office visit based on the time spent with the patient. Usually phone calls are the lowest “level 1” visits (though the rules on this may have changed). It’s possible for midlevels to bill under the MD’s level in certain circumstances Ie.g a Physician’s Assistant and Nurse Practitioner), but I don’t think MAs have ever had that ability (again, Covid may have changed the rules on it?). This smells a lot like overbilling if they were billing for more than a brief phone consult (the dollar amount doesn’t tell me what level they billed for, because rates have changed and they vary based on location).

The other thing to mention is there are contracts in place between a provider and your insurer. The practice can set any price it wants for a phone call, but the insurance will only pay the contractual amount. Often you’ll see they billed your insurer $2,000 for X service, but the insurer immediately knocks it down to the contractual amount of $100 or whatever and then goes from there. In such a case, nobody owes the missing $1,900 and it’s not overkilling. It’s only if they use a higher billing code with the insurance than what was performed that it would qualify as overfilling.

I would request the medical records for the visit note they billed you for. See if the note documents things they never asked you. If so, they’re committing billing fraud and you should reach out to your insurance company and complain to them. I assure you they will be more than happy to get their money back.

I would think your insurance company has written criteria about what specifically constitutes an “office visit” and what a medical professional can bill for under that. You should contact your insurance company, since they are the one ultimately paying the bill, and talk to someone about it.

My doctor doesn’t do that and if he did, I wouldn’t be so quick to pay it. I am betting the majority pay it without question and that’s where the problem lies.

I have both medicare and supplemental and have never had to pay co-pays but I was billed $600 for a blood test for Vitamin D by a lab. When I questioned it, the billing person at the doctor’s had miscoded it and it was resubmitted.

Just realized my answer above kept autocorrecting “overbilling” to other words. Apologies for the error.

This goes back to the billing if you ever go to an emergency room. You (or your insurance) gets billed for an ER visit. But then they get billed for the doctor, the nursing staff, any meds or equipment (i.e. splints, casts, bandages, etc), and even a hospital surcharge. If you go for x-rays you also pay for the tech, the equipment, the radiologist, etc. If you are paying for the ER visit, what is that exactly if you are paying a la carte for everything they did?

With my insurance (which I am told is a “premium policy”) if I go to a doctor or the ER, the provider is not allowed to bill for more than two copays per visit. So if I go to a doctor and get an xray, a shot and the office visit, they can only bill for two. If I go to the ER and get looked at by several professionals, plus xrays, blood work, etc., they can only bill for two.

I do think, also, as someone suggested above, that after the pandemic, when people would call up and say they had Covid symptoms and so no doctor actually wanted to see them in person, the criteria may changed but I am doubting that a phone call to request a prescription refill would qualify for that, even.

It’s not how we do things, but I’m in a government health care system. No idea how it’s done in the private sector.

According to our local doctors offices, the government requires them to physically see & checkout a patient before renewing a prescription because it cuts down on people abusing drugs. So, we aren’t given the courtesy of calling in & asking for a refill. Refills are not given unless you schedule an appointment & have an actual visit with your doctor. It’s a waste of eveerybody’s time because 9 out of 10 times they are going to give you the refill. Just guessing here, your doctor’s office is busy enough that they don’t want to be inconvenienced with a visit & they will claim they are doing you a favor by accepting your request over the phone by covering their butts with an office visit showing on their records. In most cases, copays don’t come into play & the patient is not aware that the insurance is being billed. I see it as a shady practice but unless someone turns them in, they will continue to do it. They are taking their time to provide you with a medical service, so they charge the minimum charge to cover their expense.

^^Which government and which drugs? That’s bullshit if they tell you that about any and all medication.

Triplicate drugs that is probably the case.

This is commonplace for certain medications. Some controlled medications require a consult before they can write the script to authorize the refill. This call is likened to a brief face to face,
In the case of these type’s of meds not only is it customary, it is required and will result in a co-pay.
The Pharmacy’s will not refill certain meds without such approval.

It sounds crooked to me.

^ far from crooked. It is a regulation for Controlled Substances. One can ask for a 90 day supply but it not always provided.

FDA – CFR – Code of Federal Regulation

Library of Medicine – Pharmacy Prescription
Requirements

^^We don’t know if the Q is about a controlled substance. It shouldn’t require a monthly $200 office visit charge for a phone call.

@JLeslie Exactly

It’s not about controlled substances.

Reading all responses with interest. Thank you.

A phone meeting with the MA to request refills doesn’t seem that it should quality as a visit. I’d call their billing department and ask their policy, as well as request the billing code(s) that were used for those instances. Call your insurance and ask if it is an appropriate use of that code. As far as I’m aware, MAs don’t bill… so it just seems off. If this was appropriate, then wouldn’t every doctor everywhere only prescribe one month of meds at a time with no refills? I agree with the suggestion above to have your pharmacy handle request for refills – we do this for most all meds. If you were starting a new med and they needed to monitor your response to the dose, then you would need a MD visit (either phone/virtual or in-person). But that didn’t happen.

I just had a diagnostic center tell my husband he can’t pay $400 for an MRI self pay because BCBS won’t let him under his contract he has to pay the $600 under the contract amount.

FALSE.

Not the first time doctor’s offices and dx centers have said this sort of thing. I have had billing practically threaten me when they were lying. Or, let’s say the person thought that was the rule, but they were wrong.

I called back about the MRI saying I was shopping around and they quoted me $225 self pay and the person who answered this time said yes I can self pay. Let’s see what they actually charge.

Don’t let them get away with it! Please let us know what happens.

Edit: Makes me sick (no pun intended) what they put us through mentally dealing with the thievery. It is like a slow torture shortening our lives with stress when we already aren’t well.

Sounds like evil on a stick. Should be illegal. Too bad we’re not in the kind of democracy where that would be illegal . . .

@Jeruba If you do not like what is going on then you best choice to send a message is to change providers.

@Zaku If it’s insurance fraud it’s illegal. You can’t bill for an office visit if the patient isn’t in the office. Not that I know of anyway.

The OP can help save the doctor from a bad audit and let them know they made a mistake.

@JLeslie TeleHealth is a thing and billable.

ICD 10 code for telehealth visit?
99441: telephone E/M service; 5–10 minutes of medical discussion. 99442: telephone E/M service; 11–20 minutes of medical discussion. 99443: telephone E/M service, 21–30 minutes of medical discussion.

@Forever_Free I’ve used telehealth. You yourself just wrote it is coded differently. When I have done audio or video doctor visit it has been cheaper than an office visit. It should be.

I just googled “can medical assistants bill”? Short answer, no. They don’t have an NPI number which they need to bill. If you only spoke to the MA, they should not be billing you under their physicians NPI.

@Forever_Free It doesn’t sound like they’re billing for telehealth. It sounds like they’re billing as if she actually had an in-the-office visit.

No. Run away from that outfit and report them. Change doctors and be sure to find a new doctor and ask for refill permission with the first prescription. I question whether an MA phone call could be called an office visit. It seems they think as long as you answer the phone they deserve a payment. The state licensing board can tell you.

Since the insurance company is involved and you are in the US, you could inform your state insurance commissioner.

I will add that my husband thinks it’s legal because a doctor was involved.

Find out the code they billed. There should be a visit note associated with the charge. You’re allowed to ask for a copy of the visit note. Make sure they actually talked to you about everything documented in the note. If they’re padding it with templated details, then that’s fraud.

Good point about the MA. Only doctors, nurse practitioners, and physician assistants can diagnose or prescribe as far as I know. I don’t see how a conversation with an MA is billable at all, but I don’t know the law. They are basically just getting questions answered and relaying to the doctor. I think I can do that phone call.