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I had consulted a doctor 2 times last month since I was sick (low-grade fever, cough & body pain). My co-pay is $30.
Health care provider has claimed $190 & $220 to my insurance company. I have noticed from the insurance company explanation of benefits statement that the health care provider had used different doctor name for payment claim. I visited the doctor office website, it shows that whoever I consulted both the times is a RFNP (Nurse Practitioner, not a doctor). It it legal? If it's legal why didn't they use NP's name to claim the insurance? I think insurance companies robs us since these healthe care providers are mis-using things and charges heavily health insurance companies. I am self employed and pays around $1000 for my family health insurance per month. Thanks.
$190 and $220 sound like average charges for a family practice/GP visit. I think last time I went, many years ago, my charge was around $160.
When a claim is submitted it goes under the main doctor or practice name of how the practice is registered.
For instance, when I take my son to the pediatrician, I might see a doctor or an NP. The billing goes through to the insurance as ABC Pediatrics. It is not cheaper for me to have a visit with an NP over a doctor. I have an 80/20 split insurance with no copay so I see it probably more than you do at the time of the visit.
My dermatologists office is the same way. Most of the time when I go there, I see the NP; however, when by EOB comes through, it lists Dr. John Doe. I pay the same whether or not the NP removes the mole or Dr. John Doe removes the mole.
okay thanks I didn't know that. so, doctor takes the responsibility when something goes wrong?! that's strange.
If it is legal. I it is not appropriate. In a law firm, everyone has different rates. Even the attorneys. The paralegal has a much lower rate if that is who you talk to, as well as the legal secretary, as well as a junior associate attorney. If doctors practice charging the same irregardless if the nurse, medical assistant, NP or doctor sees you, that is really not ethical in my eyes. But then our medical system is like no other.
It it legal? If it's legal why didn't they use NP's name to claim the insurance? I think insurance companies robs us since these healthe care providers are mis-using things and charges heavily health insurance companies.
Why wouldn't it be legal?
If you get your car worked on by Manny at Our Town Car Center, when the credit card statement comes in does it say Our Town Car Center or Manny who was the actual mechanic who did the work? How many other places in your daily life do you deal with a single person yet pay the establishment for the services? Trying to make the doctor's office appear to be doing something illegal is just plain petty.
As for the amounts, you provided nothing in the way of anything to even remotely indicate the rates are wrong. So they charged a certain amount, since you said it was always the same person you saw, how do you know they don’t charge more for seeing the actual medical doctor? Next time ask for an appointment with the actual doctor; just don't complain if the rates are more and you get no better service or advice.
(on a personal note, I like the NP and PA's as they tend to spend more quality time with the patient)
If you get your car worked on by Manny at Our Town Car Center, when the credit card statement comes in does it say Our Town Car Center or Manny who was the actual mechanic who did the work? How many other places in your daily life do you deal with a single person yet pay the establishment for the services? Trying to make the doctor's office appear to be doing something illegal is just plain petty.
As for the amounts, you provided nothing in the way of anything to even remotely indicate the rates are wrong. So they charged a certain amount, since you said it was always the same person you saw, how do you know they don’t charge more for seeing the actual medical doctor? Next time ask for an appointment with the actual doctor; just don't complain if the rates are more and you get no better service or advice.
(on a personal note, I like the NP and PA's as they tend to spend more quality time with the patient)
Because mechanics don't hold different levels of degrees. I just had some extensive remodeling done at my home. The work was performed by licensed journey man and his apprentice helper. I was charged $75 an hr. for the licensed electrician and $25 an hour for the apprentice.
When ever a job requires a certain level of degrees or certifications, you are generally charged according to who you see. Why are people in the US so brainwashed to think this should not apply in our health care?
When mini clinics are set up in places like drug stores or Walmart, with a nurse practitioner available, do you think they charge $200 for the consultation. So if insurance companies are paying these rates to doctor's offices, then they are being complicit in our problem here.
Aren't provider charges ( and insurance payments) driven by the CPT code submitted ?? Could it be if you were "seen" by the receptionist , the CPT code does not specify who the actual provider was, as long as they are part of the provider office staff ?
Not saying it's right, but asking if that is the real "mechanics" behind the issue ?
I like the idea of $75/hr for the "doctor", and $25/hour for the "NP", but that will never happen now.
Imagine though, if electricians, etc used CPT codes. One for a switch, another for an outlet, etc, etc. Yikes
The issue is the OP is complaining about the billing listing the medical provider's contract name instead of the actual name of the person who treated them. So even if it’s still all based on CPT Codes, the name of the provider will be the contract holder, not the specific individual who treated the patient. And to make it sound like some illegal activity is just fishing for sympathy.
The second issue is there is no way for anyone to even begin to question the cost basis based on who saw them as the OP is eluding too. The OP saw the NP twice and was billed based on those two visits. Regardless if they used CPT Codes and or CPT Codes and the professional level of the person providing treatment, the OP NEVER said they saw a regular Medical Doctor so there is no basis for the OP to question the amount charged for seeing a NP or PA versus seeing a MD because they have no idea what would be charged if they did see an MD. Essentially the OP is attempting to make it seem like they were charged doctor rates for seeing a nurse, but the OP has no idea what the doctors rates would be, so again, a baseless complaint.
I'm not sure about others, but my doctor's office does bill based on several factors. I have several different types of “office visits” on my provider statement that I match to charges on the EOBs; Office Visit, Diagnosis Visit, Examination Visit (these are normally when I see the PA or NP), Procedure Visit (may not even see a doctor or NP/PA just the nurses), Consultation visit, Annual Examination (no charge visit) and some others. Each visit has their own charge and I’ve come to recognize when one is used over the other and why and who. On the EOB they all appear to have the same description, but the doctor’s statement to me list the specifics.
The issue is the OP is complaining about the billing listing the medical provider's contract name instead of the actual name of the person who treated them. So even if it’s still all based on CPT Codes, the name of the provider will be the contract holder, not the specific individual who treated the patient. And to make it sound like some illegal activity is just fishing for sympathy.
The second issue is there is no way for anyone to even begin to question the cost basis based on who saw them as the OP is eluding too. No,`not currently in practice - by design would be the more correct answer. The OP saw the NP twice and was billed based on those two visits. Regardless if they used CPT Codes and or CPT Codes and the professional level of the person providing treatment, the OP NEVER said they saw a regular Medical Doctor so there is no basis for the OP to question the amount charged for seeing a NP or PA versus seeing a MD because they have no idea what would be charged if they did see an MD. Essentially the OP is attempting to make it seem like they were charged doctor rates for seeing a nurse, but the OP has no idea what the doctors rates would be, so again, a baseless complaint.
I'm not sure about others, but my doctor's office does bill based on several factors. I have several different types of “office visits” on my provider statement that I match to charges on the EOBs; Office Visit, Diagnosis Visit, Examination Visit (these are normally when I see the PA or NP), Procedure Visit (may not even see a doctor or NP/PA just the nurses), Consultation visit, Annual Examination (no charge visit) and some others. Each visit has their own charge and I’ve come to recognize when one is used over the other and why and who. On the EOB they all appear to have the same description, but the doctor’s statement to me list the specifics.
Granted we do not know what type of doctor that the OP went to see, but if it was a GP, then the charge of $190-$220 with a $30 co-pay might be a tad on the high side, except in certain very high cost areas. Irregardless of how the doctors offices chose to code the visits, there should be a variable on who saw the patient. But as you stated, that is not how it is done. I am not arguing that this is not how it is done. I am only saying that if the approved charge of $190-$220 is the same amount charged if the patient was seen by the medical doctor or a nurse practitioner, than maybe the system is a model all to it's own advantageous making. We all agree it is not illegal as the OP alluded to in their post.
We also do not know to the extent of the visit. Was there any type of testing done besides the stethoscope, some tongue depressors and looking in their ears? And "show me where it hurts."
If not. Does anybody else consider $190-$220 plus a $30 co-pay excessive for a nurse practitioner?
If not. Then I assume your just as giddy as a school girl with our health care system and costs.
Last edited by modhatter; 07-22-2014 at 03:22 PM..
Granted we do not know what type of doctor that the OP went to see, but if it was a GP, then the charge of $190-$220 with a $30 co-pay might be a tad on the high side, except in certain very high cost areas. Irregardless of how the doctors offices chose to code the visits, there should be a variable on who saw the patient. But as you stated, that is not how it is done. I am not arguing that this is not how it is done. I am only saying that if the approved charge of $190-$220 is the same amount charged if the patient was seen by the medical doctor or a nurse practitioner, than maybe the system is a model all to it's own advantageous making. We all agree it is not illegal as the OP alluded to in their post.
We also do not know to the extent of the visit. Was there any type of testing done besides the stethoscope, some tongue depressors and looking in their ears? And "show me where it hurts."
If not. Does anybody else consider $190-$220 plus a $30 co-pay excessive for a nurse practitioner?
If not. Then I assume your just as giddy as a school girl with our health care system and costs.
While the doctor may bill the insurance company $190-$220, the insurance company probably pays a pre-negotiated amount that is much less. I would guess closer to $60-$75. I know from personal experience that my doctor bills her personal visits at a higher rate than those done by her NP, even though they are both billed under her name. I have no doubt that there are some doctors offices that may fudge the numbers, but I know mine bills honestly.
I just had a medical procedure that was billed at $2,100 to the insurance company. The insurance pre-negotiated rate reduced the bill to $1,037, which is the actual amount paid by my insurance.
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, the CPT code does not specify who the actual provider was, as long as they are part of the provider office staff ?
