Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, October 02, 2008

Yet Another Racket

When you go to see a doctor, whatever the specialty, it's generally coded for insurance purposes as an "Evaluation & Management" service. If you need a procedure of some kind, the doctor may want to do it in a hospital or other facility, often the "Short Procedure Unit" as an outpatient. (Oh, did I mention that the facility then bills for the procedure too?) If you're just going for the procedure, then it certainly makes sense to be seen in the facility setting, though as a general rule if you're seeing the doctor for the first time for an evaluation (as opposed to, say, a gastroenterologist for a screening colonoscopy) they're not going to know what kind of procedure you might need until they actually see you.

Several of our HMOs require us to write referrals for patients to see specialists, often including a separate one for the facility if there's a procedure involved. No problem.

Here's the problem: there's a new specialist who works at a satellite facility of the hospital -- presumably the location of his office -- who requires that these HMO patients have referrals for both him and for the facility for every visit, including the initial evaluation.


We did the specialist referral for the patient, but when the guy's office called for the facility referral, I went postal. I spoke with the specialist's staffer (the doctor couldn't be bothered, of course) and here's what I got:

It wasn't the doctor; it was supposedly the hospital's policy (the one that owned the satellite facility.) All patients seen by him were charged both a doctor's fee and a facility fee, so both referrals were needed.

What about self-pay patients? I asked.

"We don't see self-pay," came the answer.

It took awhile for me to pick my jaw up off the floor. Either that, or the girl had no idea what she was talking about. Clearly it was her job to just get that paperwork, and it didn't matter much what she said or who she said it to in order to get it. I pointed out that I didn't think the arrangement was legal. Her answer:

"Oh, it must be! The hospital wouldn't do it if it weren't."

OMG! Um...yeah.

What a sweet deal for the hospital! Instead of just charging a fair market rental for office space, they get to charge a full facility fee for every patient seen in their satellite for every visit by doctors they've gotten to sign on to the arrangement.

I pointed out that my only recourse was to stop sending patients to that particular specialist. His staffer chippy suggested I talk to the hospital, since it was "their" policy. Right. Like anything I might say is going to change the way they do business, especially as long as they're getting away with it.

Excuse me while I go puke.


At Thu Oct 02, 09:49:00 AM, Anonymous Anonymous said...

I recently saw a self pay patient that came to our office after one visit with a different Primary Care doc. The doctor's office was located in a hospital's professional building.

The patient was seen at this clinic and received two bills: one from the doctor for E&M, and a facility fee from the hospital! For primary care! I think he said it was around $40.

So you can probably guess what happens to self-pay patients. They don't come back.

At Thu Oct 02, 10:30:00 AM, Anonymous Anonymous said...

A facility fee and an E&M fee for just and E&MM visit? How come insurance companies reimburse this? Wouldn't they deny the facility fee?

I wish I could start billing like that.

At Thu Oct 02, 10:42:00 AM, Blogger Lynn Price said...

Damn, I have to get into the hospital/graft business. Writing doesn't pay nearly enough.

At Thu Oct 02, 07:40:00 PM, Anonymous Anonymous said...

This is another example of sucking from the healthcare funding well harder and harder to get as much as they can before the well runs dry. You know it's a bunch of crap. Why don't you get together with a bunch of your colleagues and tell them so? Oh, I'm sorry, that would be against anti-trust laws.

At Thu Oct 02, 10:24:00 PM, Anonymous Anonymous said...

You're right--racket don't begin to cover it. We haven't heard of anything like this in our area. Maybe all this "transparency" crap the insurors are feeding us should shed a little light on stuff like this. Guess that means you start using another specialist.

At Thu Oct 02, 11:41:00 PM, Anonymous Anonymous said...

UCLA medical center did this. Each time I saw my PCP in UCLA med center's medical office building I had my PCP copay as well as a $25 facility fee. (This was in the late 90s-early 2000s). I had BC/BS insurance and they allowed it. I tried to fight it and go no where. I then changed PCP and found someone who had left UCLA and went into his own private practice. Don't know if they still do this or not since I quit getting care at UCLA med center.

At Fri Oct 03, 08:10:00 PM, Anonymous Anonymous said...

We had something like this when we went to a large center and had trouble getting it paid.

If the "facility" provides the nurse and the receptionist and the records management then you probably are costing them something to walk in the door, even for an initial appointment.

Most likely it also lets the Doctor keep all of his part, bumping his take up.

At Tue Oct 07, 07:21:00 AM, Anonymous Anonymous said...

is this the creative financing that primary care types are encouraged to consider so that they can stay financially solvent? maybe all doc's should move to the hospital professional building

At Mon Oct 13, 01:22:00 PM, Anonymous Anonymous said...

What a rip off-reminds of of an experience with a billing complaint lodged with the local MedicalSociet (yes it was a long time ago!) The patient was complaining that his insurance was over charged, and his co-pay was higher because of being billed for 8 nuclear medicine images when in reality only 6 images were taken. A reveiw of the records supported tha patients claim.

Our committee asked the nuc med doc to explain-his answer " I am allowed to bill for 8, sop I do"

At Sat Oct 18, 11:21:00 PM, Anonymous Anonymous said...

I'm an investigator with a carrier and we just started putting the hammer down on these "facility fees" for routine E/Ms. The argument from these facilities is that CMS pays for it...but CMS also only pays one global rate no matter how it's billed. If the facility charges $400 and the global rate is $200, they get $200. If the doctor charges $400 they get $200. If the facility charges $300 and the doctor charges $250, they still only get $200.

The pricing structure isn't like that in the private sector. The physician gets a fixed rate per CPT Code and the facility is usually reimbursed on a percentage discount of what's billed. One file between the facility and the physician both charging for the E/M, it was close to $800 altogether!

From what I can tell, it's really the minority of facilities that are engaged in this. Either you get an E/M charge from the physician or the facility but not both. But it's these ones doing it that give the rest a bad name.

At Mon Aug 17, 02:44:00 PM, Anonymous Anonymous said...

I'm a self pay, uninsured patient. I visited Las Islas Medical Group in Oxnard for a regular checkup. The doctor ordered blood tests and asked me to return for a follow up. In the follow up visit he gave me the results of the blood test. I was billed the hospital facility charge of $135 for each visit (code Z7500) plus high level office visit E & M codes when no detailed exam was done in either visit. I have no ombudsman or watchdog to help me, as do people with private or public insurance coverage The Billing Director told me I had to be billed this way because that's how Medi-Cal gets billed. Medi-Cal Fraud told me they cannot tell me whether or not they pay facility charges for ambulatory services because I'm not a Medi-Cal beneficiary. So I'm stuck with this bill and my only recourse is to obtain a discount.


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