Ins Billing Question | Arthritis Information

 

I asked this morning at my pain clinic what my maximum physical therapy allowance was for the year, the gal told me that their computer system was just general and didn't give that specific information????? I looked it up myself and its 60 visits.  I was concerned because they are about 6 weeks behind on there billing.

I just pulled out some of my blue cross EOB and they are billing  blue cross 0 for a one hour massage that I was paying cash out of my  pocket for each session until they found that if they bill it as the dr herself did the massage, not the massage therapist, than insurance will pay for it because I wasn't gong as often as it was getting too expensive.

I just called the ins biller on it and she said that they are encouraged to bill the insurance companies for the full amount they approve for any service. She than told me that they have different fee lists for if you are cash or insurance.  Is this legal?  They are billing 3 times the amount for the same service that I was paying cash for.  Can they do that?

Also, I know that I have a life time maximum payout on my insurance.  Is that amount based on what has actually been billed or what blue cross actually approves for a particular service?

I am really fed up with this office, I called 10 days ago, it was after hours and left a message, literally crying, and to please call me back as soon as possible.  That was when I stopped my meds and my bp went so high.  Today, the reception finally said, oh she said to make an appt and the soonest we have is 6 weeks.

I would just tell them to shove it but I get my pain meds from them and because it is oxycodone, they can only write for 30 days at a time so if I drop them, I won't have anyone to prescribe any pain meds for me!!! ,All I can say is wow! The whole system stinks. Unfortunately people deal with this everyday. Is the office you are trying to get a hold of the PT office or the pain clinic?

Michelle,

It's true that your provider may not have been able to get your exact benefits online.  It is up to the subscriber to know, or get their own insurance information.

Also, yes, it is legal for a provider to charge a patient that doesn't have insurance coverage a different amount than they charge the insurance company.  What would be illegal is to have a provider charge each insurance agency a different fee.  You can legally offer a discount to patients that have no insurance, as it is cheaper for the provider since they don't have to bill insurance, etc.  It's sort of a discount for paying up front the day of the service.

Providers can set their fee for each service, however, most have signed a contract with an insurance agency aggreeing to their fee scale.  i.e., you can bill BCBS 0 for something, but if they signed a contract saying they would accept 34.00 as payment in full then the provider knows he's only getting 34.00 and cannot bill the insured for the difference.

Insurance is very confusing....I hope that I have not confused anyone more.  I deal with this every day, but sometimes it is hard to explain.

The bottom line, everyone should know their insurance coverage.  It is not up to any provider to find that out, it is your responsibility.  Also, lots of people do not read their EOB's....your insurance company sends you this to keep you informed.

Also - when it comes to being 6 weeks behind on billing....if you have a straight copay, you pay your copay and there isn't really any worries, providing your services are covered.  It's when a patient has a co-insurance there becomes a delay in billing.  If someone comes in to our office with a co-insurance, i.e., an 80/20 for example, I can't bill them for their 20 percent until I get payment from their insurance company, telling me what they are paying, what is not allowed, etc, and what the contracted fee is for the service.  Because it can take 4-6 weeks for an insurance company to process a claim and send our  checks, I have no choice but to bill that late.  It's not always the fault of the provider.  Insurance is a pain!!!!!

Debrakay39335.7692476852I have a question Michelle, Is the physician actually doing the massage?  If he/she isn't then they cannot bill for that.  Maybe I misunderstood you.  Actually, the charges connected to the CPT (procedure codes) should be one fee. 

The fee can be discounted for insurance companies, but the fee should always be the same.  A bill to Medicare would have the same charge as to a private insurance, but the contract between the physician and Medicare dictates what Medicare will reimburse.  An office can offer a discount to private pay patients from the original charge.

I agree with Debra that everyone is responsible to find out what their insurance covers.  Most people don't realize that one of the forms they are signing when they first comes to a physician office is a patient financial responsibility form.

Insurance is confusing.  My medical reimbursement students are always shocked when they start to learn the ins and outs of coding and billing.

Alright Michele, whenever I read the title of this thread all I can think of is the Chesire cat singing "Twas brillig, and the slithey tomes did gire and gimble..in the wabe"

Come on, you can see it too, right? "ins billing" - "twas brillig"

Tell me I'm not nutty??

Thanks for being more clear.  I was saying what you said regarding pricing/contracts/discount for no insurance patients, but I just couldn't put it in to good words.  Definitely going through a foggy brain time.  I am losing my "simple" words.

Thanks!!!  I feel really bad for patients who are clueless to their insurance coverage.  I'm trying to really sink it in to my boys that when they go for a job after college, the insurance is more important than the dollar figure.  It's all good; until you get sick.

I work for an optometrist and do bill insurance for vision.  I have a pretty good understanding how the whole thing works.  I understand that the insurance companies only "allow" a certain amount for a service and that if they are a participating dr they can not charge the patient the difference.

I also understand it is my responsibility to know my benefits but it just seemed like a load of balgonie that they couldn't look that up because when I first started going there they did pull up my benefits and I saw the listing and it was very extensive.  I think it was a matter of she didn't want to bother.  Which is ok, I looked it up myself.

No, the dr herself is not doing the massage but yes that is how they are billing it.  I see a licensed massage therapist and she does the massage.  However, my insurance company will not pay for that so they billing codes they use show that the doctor or a physical therapist is actually doing.  I KNOW this is illegal.  They want my money so they do it as they know I can not afford it any other way and I am sure they are doing this for a LOT of patients there.

I would love to tell this dr off but I am about out of drs at the moment and she is the one who prescribes my pain medications which is one of the few medications I am still taking.

As far as them being behind on the billing, I need to know exactly how many supposed physical therapy sessions they have billed as I am only allowed sixty and I was getting some other physical therapy treatments from them as well that I have stopped.  Is it wrong of me to expect them to be able to answer how many pt sessions have been billed total, up to date?

No, I don't think it is unreasonable for you to ask that Michelle.  Did you explain to them why you were asking, that you just want to make sure your sessions will be covered?

Does your plan year start again in January?  Have you been averaging more that 1 session a week?  You are probably fine on the number you have left.

When I was doing PT (a couple of years ago), the insurance also had a limit of visits per year.  Maybe it was 60, maybe it was fewer.  But the problem was that they wouldn't cover it at all unless you went 2-3 times per week.  The rationale was that going less often meant you were basically starting over each time rather than building on the benefits of the PT.  So if I had to go 2-3 times per week, my coverage wouldn't last for the whole year.

I know most people go for PT for a limited time, maybe 2-3 months, but for my problems that wasn't going to do it.  It turned out to be moot.  My physical therapist, who was sort of specialized in fibro patients, treated me for months then finally said that the PT wasn't doing me any good without exercise to back it up, and the exercise was too painful to do.  So even going 3 times a week was like starting over each time.

Anyway, I digress.  Yes, Michele, they should be able to tell you how many visits have been billed this year.

I don't have any thing to add... Just wondering how you are doing off most  of your meds.Hi again Michelle,
One of the reasons that health care costs are so high is billing fraud.  If the visits are being billed as being done by the doc, but actually being done by the massage therapist, that is fraud.  You could report the fraud, but I see that you are are in a bind. 

I do not think they are doing it for you as a favor.  They are potentially committing a crime to line their own pockets.  If they wanted to do you a favor they would give you a discount on the charge.  I often ask my students what they would do in a situation when they are asked to commit fraud (potentially a federal case with fines and federal prison) or to report their bosses.  They know that they will lose their jobs if they do.  I always ask them if they they would really want to work for a crook if they could keep their jobs.  I would wonder what other unethical/illegal things they are doing to their patients.

Good luck!

Mary, I stopped working for a medical office because they were doing things that were not legal with their billing practices.  It was fraud, and I wasn't going to do that for anyone.

As far as accepting a massage knowing that they are billing it through a doctor I personally wouldn't feel comfortable doing that.  I know you like the massage and can't afford it on your own, but what's going on is wrong.  Do you really want to be involved in allowing yourself to be in this situation?  To me a massage isn't worth putting myself in a position to be doing something that's not on the up and up.

As far as asking the therapist how many visits you have been billed for, I agree, they should be able to tell you.  However, you should know how many visits you have been to.  You have the answer also. It's not hard to figure out, I'm sure you have a calendar of your appointments.  Add them up.  It doesn't really matter if they have been billed yet, if you have 30 visits a  year, and you have used 36 but they have only billed 25 so far; you have still gone over your benefits and will be resonsible for the 6 visits in the end. 

 Everyone has different insurance.  Some companies have a dollar cap, i.e. ,000 worth of physical therapy visits per year.  Others have a 30 visit per year, and some have a 30 visit per injury, per year.  Again, know your own policy. 

 

I do have an appt book with my appts in it.  However, I a not sure when they started billing as I was paying cash of of pocket for a while.  In a perfect world I would have kept all my receipts but I usually go twice a week but not always and I have so many papers.  As I said, I work for an optometrist and I understand ins billing to a point.  I know it is MY responsibility to know my own policy but is it really hard for them to tell me how many visits they have billed to my insurance?  My patients call me all the time and ask me when their insurance will pay for their glasses again and the last time they were in and such and I have problem looking it up for them.

The massage is more than just a massage you would go get for a day at the spa or something.  For whatever reason they haven't figured out yet my lymph system doesn't drain the fluids from my hands and feet and they stimulate the lymph system to help reduce the swelling.  They also stretch my fingers and toes, without it, they would be all curled up.  They really stretch most everything.  I have also been dx with unexplained multiple muscle constrictors and they have to use a fair amount of pressure to get those contrictures to let up and it hurts more often than not. It also helps me to manage my pain. Its not just a matter of "oh, I feel a bit tense today, I think I will get a massage" kinda thing.

I do understand that what they are doing isn't proper but they assure me that it isn't illegal although I don't understand how.  If that makes a criminal, I guess I am.  But, I know that I pay 6 a month for just my insurance premiums and my coverage has gone down by 20% and my co pays for office visits and drugs have gone up as well.

I KNOW they are not doing me any favors and  are just trying to increase there pockets and as I said, I would rather just ditch this dr and her office totally but right now, she is the only doctor that I really have other than my rheumy.

I plan on rectifying that but I am waiting to see what the new dr has to say next Thursday, he is an endocrinologist.  Depending on what he says, I am hoping that will point me in the right direction so I can figure out what sort of dr I need for my primary.  If you remember my primary that I just fired said I was just fat and depressed and wouldn't help me.  So, if the endo agrees, than I guess I need to make appts with a shrink and a dietitian.  But, if he can actually figure out whats wrong with me after 3 years, than I will know what sort of treatment I need and what sort of dr to go to.

Marian, thanks for asking.  I am very stiff and extremely fatigued, my pain has gone up but only about a notch so I guess that is good.  All my symptoms are still there, stopping the meds certainly didn't fix anything but its good to know that I am taking a LOT less drugs.  The swelling in my hands has increase and my feet and ankles swell after very short periods of activity.  I went to the grocery store this past weekend and I had two watermelons for feet by the time I got home.

Michelle,

Thanks for the additional information.  The Physical Therapy office should definitely be able to tell you when they started billing.  Also, a quick call to your insurance company, or looking at your EOB will tell you as they would have to bill for an initial evaluation or a re-evaluation (sometimes allowed on certain insurance companies in this situation).  The CPT code for an initial evaluation is 97001 and for a re-eval it's 97002 

If it's more than a massage, and they have a licensed massage therapist doing more of a medical massage, perhaps they can bill it under those circumstances.  I misunderstood, sorry about that. 

I hope you find a doctor that you are comfortable with and an office that has their act together.  Good luck.

Hello again Michelle,

I hope you didn't think I was saying you were doing anything unethical.  I didn't mean that at all.  I know employees who are put in the situation of false coding and billing and like Debrakay they are put in a very bad situation and I think that if a Dr. is going to commit fraud, what else are they doing wrong.

If they are doing "manual therapy techniques" which includes lymphatic drainage, than they can charge for it differently. That is under "therapeutic procedures", possibly code 97140.  I hope that it is helping, I know I had one lymphatic massages to help with my sinus problems of all things.  It did give me some relief, but I ended up had surgery anyway on them. 

I hope you are doing well.  You are a very strong woman with conviction and I am proud to "know" you.

Copyright ArthritisInsight.com