Doubling Over


“Good news! We got the results of your coding audit and you missed only three things. Please add a 99214 with a modifier to these three office visits so we can post the charges.” The email went on to list the names and dates of service that I was to address.

I go through this every audit. They always find something to nitpick about every year. One year they tell me to do X. I start doing X. Then the next year they tell me I should never do X, I should be only doing Y. Y was what I had been doing before X. And so on….

I don’t like being wrong. I don’t like making mistakes. I don’t like being told what to do, especially if it is something they are going to change on me next year.

Feeling defensive, I looked back at the visits in question this time.


“No way in hell am I going to add those charges. If coding wants to talk to me about it, I am happy to have a discussion with them but I will not be making these changes to the superbill.”

The office visits in question were yearly physicals. Yearly physicals are considered preventive care by insurance companies and as such, the office visit and routine screening labs are covered at 100% by the insurance company. It is not applied to a deductible. There is no copay, no out of pocket expense. 

A “free” visit.

What the coding people wanted me to do was tack on a routine office visit charge in addition to the physical exam visit charge because I addressed something new, like back pain, or made changes to meds for one of their chronic medical problems, like increasing their blood pressure medication.

The problem with this is that particular charge is not a preventive service. It will go to the patient’s deductible. They will get a bill for another $120-140 (or whatever the contracted rate is for their plan) and for most insurances, that means the patient will be paying that entirely themselves out of pocket until their deductible is met. Meanwhile, I get paid for two office visits in the time slotted for the one.

I have been practicing medicine for over ten years. I have known for a long time that it was within my rights to do this but I rarely chose to except for a handful of times in the most extenuating of circumstances.

Just because we can do something does not mean we should do it.

When I have patients skipping specialist referrals and imaging and labs and meds that they really need because of the increasing costs, it bothers me. I need to make money. I do. I have to be able to purchase supplies, pay my staff, and pay the office rent. I need transportation. My kids need clothes, food, and a roof over their heads. The kids will need to go to college and I will need to retire eventually. I make more than enough for this right now, though. I don’t have to double dip. 

The thing that puzzles me at this point is why is coding making it an issue now, this year? It isn’t anything new. There is a lot of paranoia in the medical world about what the future holds for physicians financially, especially with all of the crappy changes to Medicare reimbursement, and that may be part of the reason corporate is starting to pressure us further to maximize our bottom line. I do have to make money for them to make money, after all.

And then I start to wonder. Is there something they know that I don’t?

Should I be grabbing everything I can now and retire early… get out of this business entirely before it collapses so I can go do volunteer work somewhere I am really needed?


102 thoughts on “Doubling Over

  1. This happened to me at my own annual exam and I’m a doctor. Patients don’t have a chance. I had my preventative care exam and told my doc who’s a friend that I was changing my own medication dose slightly. The “coding team” saw disease and tacked on a 99214. I spent 15 minutes in his office, made my own medication change and paid an extra $140. It’s B.S.
    No don’t cave in and try to make more money and get out. I don’t think it will work and you’ll be miserable from going against your own ethical code.

    Liked by 4 people

  2. I’ve *liked* this post but I really don’t. In the world of audit, it’s called revenue leakage. I understand it, but seeing its implications on the other side of the financial statements is really an eye-opener.

    In my working world, it was a common practice for the senior management team to periodically spend time in the call centre on the phones listening to calls … our equivalent to patient visits, I guess. The idea was to not lose sight of the customer and the issues they have.
    It’s too bad that the medical community doesn’t have something similar. A little bit of empathy can go a long way.

    … yeah, I know … I see the world through rose-coloured glasses.

    Liked by 3 people

  3. I think this is the insurance industry’s way of making sure those “covered” visits aren’t. The whole point of the no cost physical is to catch things early, and get people to the doctor so that can happen. People who avoid the doctor because of cost won’t go to a doctor again if they feel cheated.

    Liked by 3 people

  4. Our doctor’s office (part of one of the major healthcare groups in our area) has been cracking on down on this. Every physical all of us have had this year has resulting in paying a copay. Nothing mentioned that took more than a couple minutes conversation either, and nothing I can’t think of anything we talked “extra” about at all for my daughter. We only pay a $15 copay, so easier to pay than fight it.

    Liked by 1 person

  5. I had a doctor do this to me more than once. Good for you for standing firm.
    When I called them out on it, they said “well, your insurance is paying for it”, but it wasn’t. But even if it was…no wonder insurance costs are so high. There is no end to corporate greed…(K)

    Liked by 1 person

  6. “Double dipping” says it all. If only all our health care workers would speak so loudly about this. I saw A LOT of this many years ago while training in a V.A. (Veterans Administration) hospital. When I questioned the duplicate testing on various patients I was told to ‘not worry about it-they aren’t paying for it anyway’. Well guess who is! Just ridiculous.

    Liked by 2 people

  7. Pingback: Doubling Over | Whats Next

  8. Well that’s intriguing. I had never fathomed so much .. I don’t know the word, politely, for this situation. Your office bureaucracy stories never cease to amaze and disappoint me. Do they still make doctors take ethics? Maybe the connected fields need to take some ethics classes.

    Liked by 2 people

  9. Ugh – I don’t envy anyone who has to deal with this sort of nitpicking. Even if it only happens periodically, it just seems a nuisance. I’m thankful the law doesn’t have as much of this as most professions (though I am sure it will creep in – and once it does, I’ll move to taking dog and cat pictures for a living!).

    Liked by 1 person

  10. If the system did collapse, it could open up room for something better. People are always going to need doctors. But more likely things will change gradually in one way or another. I like Joey’s idea, too. Ethics classes for everyone!

    Liked by 1 person

      • I have seen that in the 30 years I’ve worked in mental health. Part of me wonders if it really did kill one of my collegues, though cancer was the official diagnosis. Everyone loved her as a counselor, but she couldn’t keep up with the paperwork.That’s why I’m semi-retired now. I’ve been saying for years, “I’m not going to let this job kill me.” Don’t let it kill you, Vic! Keep your sense of humor and keep doing the right thing, until you can retire and volunteer.

        Liked by 1 person

  11. Sometimes, the more I read your posts, the more I think insurance just complicates things and, because of all the middle-men, makes everything more expensive. It started out with good intentions, I’m sure, but now it seems like just this behemoth that nobody can fix and nobody can stop.

    Liked by 2 people

  12. Working as a hospital doctor I was for a while almost immune to the changes in the outside world. But the penny pinchers were there, they are just more obvious now in telling me how to do my job. I watched the layers of hospital breed and multiply to produce just waste and inefficiency – yet we are told to work harder and smarter! Like you, I’m thinking of volunteering somewhere, when the kids are a little older. Great post, thabkyou

    Liked by 1 person

  13. I am “shocked”… NOT! I hate our coding system. But what is worse is the billing departments who push crap out for bills. I have been fighting three charges for labs when I never had labs drawn. It is over a year. They agreed to one so far and still rebilled it. They send inflated bills hoping the customer says “Its not worth fighting over” and they pay. I never pay a bill when they first come because they often “correct” it and do not send it again.

    Liked by 1 person

  14. Your post make so happy to be out of the medical world…..retired and I don’t miss it at all…only the residents….the innocence ones…who bought in to make themselves a better life….hummmm when did greed take over…..double dipping, extraneous charges because they can ! Glad the kitty is dong well….have a good rest of the week…its almost over….kat

    Liked by 1 person

  15. We need physicians who stand by their principles. So many people look to them as the final expert in all things, so if a bill showed up in the mail they (especially the elderly) just assume it’s as it should be. A person who stands up for what they believe in will always be able to look in the mirror without flinching…

    As always, a thought provoking read, Victo.

    Liked by 1 person

  16. Companies are so focused on profit, they forget who brought them to the dance – the client. Screwing the client is not a sustainable strategy. I’ve seen this over and over in many businesses and it always crashes when someone figures out how to give better service with less cost. Some huge corporations have come crashing down that way. GM, Chrysler, Nortel, etc, etc – all paying huge bonuses and big wages to corporate levels when the reality was very different. Sometimes it takes many years before the crash and sometimes there is just a slow transition but it happens inevitably – don’t give value to the client and as soon as an option opens up they’re gone.

    Liked by 1 person

      • I’ve had this same argument in many businesses including Transportation, Retail, Truck sales, etc. Keep it lean and mean and honest and give good value and you’ll always have a job. Screw the customer and your days are numbered.

        Liked by 1 person

  17. Go with your gut….you know where this is leading. The future of medicine is uncertain,the insurance companies are looking for any excuse not to pay. This seems to keep getting worse. Your patients are lucky to have you.

    Liked by 1 person

  18. A scotsman cafe-owner at Covent Garden last year told me: (You can add the scottish R’s)
    “Trrrouble with today’s worrrld, is just Grrreed!”
    Amen to that. think of Volkswagen, number 1 car manufacturer in the world at the top of its reputation who had to fake a software to bypass pollution checks? How more stupid can one be.
    Stand firm. And my compliments for doing so. 🙂
    (I hear too many stories of doctors putting in fake bills and splitting with the hospital) 😦

    Liked by 1 person

      • Well now there’s an interesting statement Victo. This little word “greed” and its older brother “avarice”, power our economy. It is the selfish desire for more physical belongings and for power that creates markets and keeps economies growing. When I did my little stint in exploring capitalism it bothered me that was so. How could a negative concept like greed hold so much power and contribute so much to our world? We have actually acknowledged this and built in checks and balances to our economy. so that greed is limited in what it can do – while at the same time encouraging it.

        With a bit if thought I realized that the core concept in greed – when you take out the “selfish” part – is having knowledge of and being a part of something. If we take that concept and apply it to the spiritual world rather than the physical world, the concept is expressed as awareness and integration. In fact on those rare days when we feel like we are doing and being exact who we are – we call that being “One with the universe” And that means we feel as if we are a part of all things and being such we desire all others to be that way as well. In other words we seek to give our kittens that which allows them to be the best kittens, we seek to give our clients that which allows them to be the best person they can be (even if we disagree), and so on.

        There is much more to be said but I’m sure you get the point. Greed is the inappropriate expression of unity in the physical rather than spiritual world. This empowerment of the negative comes from the fact that most concepts have opposites that are minted from the same coin – just the opposite side. For instance – love and hate are on the same coin of “faith” wherein love is the faith that all others will wish only the best for you and hate is the faith that all others wish only the worst for you. That power has been used by those like Hitler to build their power in the physical world. And so it is with greed.

        Hence greed is the misapplication of unity in the physical world rather than spiritual. It derives its power from unity. Which, as an aside, is why possession feels good – for a short while. Did you ever notice that the good feelings derived from, say, retail therapy fade ever quickly? Same reason – the acquisition feels good in anticipation of unity, but soon after disappears because unit is not achieved. So we need more – hence greed.

        Liked by 1 person

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