Two West Hartford residents who were thrown out of one of largest medical practices in the state for complaining about its billing practice have won at least a minor victory by forcing the group to be more transparent about its charges.
Darlene Susco, the owner of a marketing firm, and Don Reder, a professional mediator and arbitrator, filed complaints last year with the state Attorney General’s office accusing the Hartford Medical Group of double billing them for their annual physicals – by charging both for the physical and for consultations during the physical.
Following a lengthy investigation by the Attorney General’s office, the Hartford Medical Group has changed its policy and is now informing patients that they might be billed extra when they go for their physicals.
The Medical Group, with about 50,000 patients in the Hartford area, has insisted all along that it had the right to bill for additional charges if the physical included anything that was not included in its definition of what a physical.
However, it did not warn patients about that policy prior to their visits, which had been established in the last two years.
Reder and Susco were told by the group that they were no longer welcome after they complained about extra charges from their physicals which were not covered by their insurance carriers. Normally annual physicals are paid fully by health insurance companies.
While my internist and many other doctors consider a physical to be an all-inclusive session that would not result in extra charges even if new symptoms were discussed or prescriptions were simply renewed. Other doctors and medical practices obviously want to make more money from the physicals and attempt to add on as many charges as they can.
They are able to tack on these extra fees because there are no set guidelines by the American Medical Association or any other medical body that specifies exactly what an annual physical should include. This permits doctors and medical practices to unilaterally decide what is included and what they can bill for extra.
“We discovered,” said Attorney General spokesman Susan Kinsman “that the threshold determination of when significant additional services are rendered is made largely on a case-by-case basis and … appears to permit services that may seem minor to a layperson, to be considered significant to a physician or billing agent.”
“Mindful of this position and that the issue is just coming to the attention of consumers because (1) preventive exams are newly being encouraged through zero cost share benefits, and (2) many more consumers and employers are opting for high-deductible plans which have no cost share for the preventive exam, but high, initial out-of-pocket expense for regular office services, we determined that what was truly lacking from the consumer perspective was adequate notice of when these additional services are about to take place and patient options relative to those additional services.
“We thus worked with the Hartford Medical Group to address this primary issue, which was notifying patients when their physical examination crossed the threshold of a preventative wellness exam into “significant additional services,” for which they may incur an expense, depending on their deductible under various medical plans,” Kinsman said.
“The Group drafted, implemented and distributed a policy requiring its doctors to advise their patients when an examination was going beyond the scope of the preventative wellness exam, i.e. when a condition was discovered that required additional examination, tests or treatment significant enough to trigger the use of modifier 25.
“At that point, the patient is to be advised by the physician that he or she has determined that additional services are needed, but such services may cause the patient to incur a co-pay or cost share, or deductible expense, and further that the patient my opt to receive the additional services at a later time.
“A letter is also being sent to patients at the time they schedule annual physicals, explaining what the preventive or wellness exam entails and that the doctor will advise whether additional services may be required, which may trigger costs to the patient, depending on their deductible, co-pay, or coinsurance for non-preventive services.”
Dr. Kent Stahl, medical director and ceo of the medical group, said:
“The complaints last year helped to shed light for us all on a complex and confusing aspect of medical billing. But they gave us an opportunity to work to become a leader in transparency. We worked closely with the Attorney General to create clearer policies that we believe better serve our community and our patients.”
My personal belief is that the more physicans are required to disclose about their fees and their conflicts of interest (like when they are paid by drug companies or they use medical devices they have a financial interest in) the more ability patients will have to make rational choices. They can chose to have a doctor who has their health as their primary concern, or they can chose a doctor whose primary concern is to make money.
From a doctor
Interesting article. As a primary care doc for over 25 yrs, these very issues have been in the forefront of my daily practice. While many doctors are unscrupulous in generating as much income as possible, most are not. The issues are very complex. I thought I would supply a few points of information.
There are indeed “Guidelines” for what a Preventive Health exam entails and they are published by the American Medical Association as ‘CPT’ codes. It is a discrete much like the courtesy check at Expert Tire for $19.95 in which the garage inspects your car and finds out what’s wrong, but charges extra to fix it. At a preventive health visit the medical history is documented, symptoms and conditions are listed, and recommendations made for follow-up. The intervention that occurs for that visit is or should be prevention. Thus counseling and advice on exercise, nutrition, cancer screening and immunizations are addressed. Most docs throw in some interventions for illness, but they are shooting themselves in the foot as it is not a covered service under the insurance company guidelines. Insurance allows for the modifier 25 if additional services are rendered, but NO insurances actually pay for that. If a doc “participates” with that insurance he may not balance bill. If he does not participate but submits a claim , he may balance bill……but he better warn the patient first!…it is administratively easier to ask the patient to return for followup to address their health concerns. If they arrive for their “preventive “ and have chest pain or a sinus infection, the “preventive “ visit should be postponed. Unfortunately, many patients see the annual “preventive visit “ as a chance to present a lot medical issues for free
I was told by the Drs front office folks that if I brought up medical issues duing a physical, I would be charged for an office visit. So I only answered the Drs questions and did not question or prompt any discussions on my own. The DR asked how my asthma was doing and said on my next OV we would look to change the meds. I said OK. That 60 second exchange prompted them to bill me $15.00. Totally unfari and people in the billing group are now threatening me with a collection agent even though I disputed this in writing (they say they did not get my letterand even if they did, they stand behind their bill) What a load of garbage. I only went for this wellness visit because it was required by my health insurance. The Doc got paid for his time doling the wellness part and billing extra for an OV due to his raising the topic of my asthma was unfair and deceptive – I assumed it was part of the usual Q&A of a wellness visit. Big medical groups may be good for some things but they stink when it comes to being fair and honest