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I always ask for the out-of-pocket cost before coming into the exam room. If it's repeatedly beyond my expectation, change doctor.
Good luck.

fpduck said: [Q]Doctors can bill for a physical and a sick visit the same day, but they have to put a modifier code, i think code -25, with their bill to the insurance company. The reason they don't is: 1. they don't know how to 2. they are afraid that they may not get paid for both visits (which often is true). I don't know if their office can resubmit the claim for the services with the appropriate modifier - something you might want to ask them.
Correct on the modifier, but some companies may not accept that practice and reject the bill regardless. It really depends on how the visit was coded and the labs coded (possibly two separate issues). eg: was the visit Primary: fever, secondary: well visit/healthy exam or vice versa? Labs: were they coded for well visit?.

OP, you've run into the common problem with doctors, billing/coding people, and insurance companies. This is the MAIN reason why most physicians refuse to do two separate types of visits on the same day (many parents with children will surely tell you stories on this), becuase coding is difficult and the insurance company often will reject the claim for well visits and sick visits and end up making either the physician and/or patient eat the cost.

Your best alternative is to request the physician's coding person to recode and resubmit the bill to your insurance company. If you want to be specific, ask the coding person to see the labs and what ICD-9 code was attached to each lab. I bet that the physician placed a single ICD9 code (or both physicial and fever codes) on a single sheet, not two, so it'll be nearly impossible to delineate which lab was for what.....thus, the insurance reviewer will simply reject the claim as 'unnecessary'.

PM me if you have more ?s.

fpduck said: [Q]Doctors can bill for a physical and a sick visit the same day, but they have to put a modifier code, i think code -25, with their bill to the insurance company. The reason they don't is: 1. they don't know how to 2. they are afraid that they may not get paid for both visits (which often is true). I don't know if their office can resubmit the claim for the services with the appropriate modifier - something you might want to ask them.

Actually the 25 modifier code is not used that way. A 25 modifier indicates that you had a procedure done that day that was indepenent of the visit or that you had a procedure done that day that was decided on at the time of the visit.

A 57 modifer indicates that visit was either unrelated to a major surgery the following day or that the visit made final decisions for proceeding with the surgery the following day.

Ok...I used to manage a pediatrician's office and also did medical billing. I used the modifer -25 many, many times and successfully obtained additional reimbursements from insurance carriers. I don't know the specific circumstances surrounding OP's experience, so I can't offer any advice on how I would have coded the office visit.

I pulled this information from some of my reference books I have:

Modifier 25

Definition: Significant and Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

Modifier 25 is used to describe separate, distinctly identifiable services from other services or procedures rendered during the same visit. Always attach the modifier to the evaluation and management code.

Some examples of separate and distinctly identifiable services are:

- Initial hospital visit, initial inpatient consultation or hospital discharge and an inpatient dialysis service. Modifier 25 would be appropriate on the E&M code.
- Unscheduled E&M service performed the same day as a preventive exam-when the service is in addition to the preventive care.

Hope the info helps...

This is a ridiculous post.
Were you sick? Did the doctor help you out?
Were you trying to save a few bucks combining two issues into a single visit to save on a copay?

YOU DON'T GET A PHYSICAL WHEN YOUR SICK. END OF STORY. Any abnormalities seen/found may be due to the fever. If the labs were for the fever, then you should pay for the bill... though that seems like a pretty big bill for labs. If some labs were for routine stuff, and some for the fever, then you have to talk to the lab's billing dept to ask the doc's office to change the diagnosis for what each labs was for.
Doc's don't get into the insurance side of the business. Most try to treat all patients the same, regardless of how good their insurance is. Just a heads up; If a doc gets paid 66% of what they bill, that's pretty awesome return. Many are down in the 30's because of hospital work, where they have to see everyone, including the people with NO insurance or money. When was the last time you could pay 2/3 of you bill and forget about the rest???

[Q]Many are down in the 30's because of hospital work, where they have to see everyone, including the people with NO insurance or money. When was the last time you could pay 2/3 of you bill and forget about the rest???

here, here! <img src="i/expressions/face-icon-small-wink.gif" border=0> [though i'm sorry you got caght up with a surprise bill, OP]

I think OP is fighting a losing battle. Similar thing happened to me (actually to my kid), went in for a checkup, (which took like 10 minutes for a 45 minute appt), dr asked if we had concerns, we mentioned one thing, she "did another exam" (another 5 minutes). They charged for the checkup plus a level II appt. Insurance rejected saying they only pay for one appt per dr per patient per day. I spent 6 months arguing and finally winded up paying for the "2nd" appt. In my case they kept saying the "biller" thought it was appropriate. I asked to speak to the biller probably 10 times, each time was told she would get back to me and she never did (appalling service) My argument to the phone Jockey that for a kid's well-child they block out 45 minutes, yet we were in and out in 30 max went nowhere. This was a load of BS, at a well-child check they specifically tell you and ask you to bring up any issues, which we've done numerous times in the past, and never been billed twice. I ended up just switching dr's and never going back to that office. I also had other issues with that office, they just were sleazy all around with their billing practices.
My experience with dr's offices (I've been to many with the kids), is that most offices just take what the insurance pays and NEVERS hassles you, yet a minority (~30%?) are very picky/sleazy and will constantly be trying to get you to pay more. Just avoid that type. You can easily identify the 2nd type because they send you a billing statement every month even before your insurance has had time to pay. Same exact behavior applies to dental offices.

One suggestion for OP, call the bloodwork provider (lab) and explain the situation. My experience is that $451 of bloodwork would be paid about $100 by the insurance. Maybe you'll get lucky and they'll just charge you what your insurance would have paid.

Edit: spelling



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