In an effort to help MEDucate patients about some of the basics of their health insurance benefits, here is an overview of how doctors bill their office visits.

The cost of a visit to a doctor is dependent on a variety of factors:

Is this a consultation?
Is this a new patient visit?
Is this a yearly well visit?
Is this a visit with an established patient with specific health complaints?

Each of these visits is defined by its own set of procedure codes that are used to identify the service type for the purpose of submitting those claims to health insurance companies for payment. In addition, these service classifications are further delineated by codes to specify the intensity and complexity of the service provided. In all cases except for yearly well visit procedure codes, there are five levels of service available to be used, ranging from minimal time and basic clinical involvement to significant time and complex clinical management. Accordingly, the cost for each of these services increases as its level of clinical management increases.

Why is this important for you to know?

Given that almost every health insurance policy includes a deductible, policy holders can be subject to shouldering significant costs for their care until their deductibles are reached. For people who don’t seek medical care very often, those deductibles might not be met in a given year. That means that those people could be self-funding their care, and therefore, could benefit from controlling their medical costs in any ways that they can.

In the case of the office visit, ensuring that the visit has been coded appropriately could translate into hundreds of dollars of savings. For instance, if a visit to your doctor was scheduled to exam your throat for throat pain, and that visit lasted 10 minutes, it should have been billed at a lower service level and fee than it would have been billed at had that visit lasted 30 minutes and included more comprehensive evaluation and procedures including strep cultures, ear wax removal, blood draws and other diagnostic tests. According to government studies, physicians frequently upcode (code at a higher level than justified by the clinical notes for the encounter) which results in higher reimbursement for the doctor, and thus potentially translates into higher costs for the patient.