This post is not my typical style. It is a real life story that I feel needs to be told. And, it’s my story. I hope you’ll read it and respond – in words and action.
Something is wrong with healthcare, and reform is needed. I get that we need to negotiate what that means. No matter how hard I try, though, I don’t get people who disagree with the very notion of reform.
The problems with the healthcare industry don’t always involve major surgery and big money. Here is a much simpler story illustrating one reason reform is needed.
Let me start at the end.
Last week, I mailed a check for $15 to my gynecologist to cover my co-pay for my annual exam. The remarkable thing about that $15 is that it was the second co-pay for the same appointment. I didn’t know that could happen. Here’s how it did.
Some background information:
I am blessed to be generally quite healthy. I don’t have any serious ongoing health challenges. I take no medicines, I have no chronic diseases. I’ve had kidney stones, a touch of arthritis in my shoulder, a few mammogram callbacks, one negative biopsy; fortunately, nothing more serious than that. About two and a half years ago, I also had a hysteroscopy to help treat some menstrual issues I was experiencing – and that is very much related to this story.
Why I view healthcare the way I do:
I have been a supporter of some form of universal healthcare availability and healthcare reform for as long as those concepts existed. In large part, my opinions were formed while watching my parents struggle through numerous diseases (Cancer, Hepatitis C, Alzheimers, Parkinsons) and various surgeries (hysterectomy, colonoscopy, lung removal, fractured ankle) while having to carry their own health insurance. Carrying private health insurance 
(BC/BS) was one of the highest expenses my parents had, eating up about 20% of their income. My Dad was a bricklayer and his employer of 25+ years did not provide this benefit.
Their struggle with the cost of healthcare was ongoing, but most seriously revealed itself in the early 90s. Because his brother had been diagnosed with colon cancer a few years earlier, my Dad was pretty certain that his low back pain and dark stool meant he also had colon cancer. However, he delayed confirming this suspicion and endured a great deal of pain for about two months longer than he should have due to the insurance rules in place at the time. He would have been significantly penalized – a pre-existing condition would not have been covered – because he was about to change insurance carriers. He waited, and the tumor grew. This most definitely had an impact on me and strengthened my feelings about access and affordability of healthcare.
One doctor visit, two co-pays
This past November, I had my annual gynecological exam. My doctor performed the usual breast exam and pap smear. As he did last year too, my doctor asked how I was doing with the previous menstrual issues. I told him that while the surgery helped for about a year, the problem was back to where it was pre-surgery. We went on to discuss scheduling a couple of follow-up tests and also discussed the possibility of another hysteroscopy. With menopause around the corner, both of us were trying to avoid the major surgery of a hysterectomy. The exam and discussion lasted less than fifteen minutes. I paid my $15 co-pay on my way out.
About a month later, I got a statement from my doctor indicating a balance due of $15, for the co-pay due for that visit. I sent the bill back, with a note indicating the check number of the payment made at the appointment.
A few weeks ago, I went in for my pre-op exam, and was told that I still had a balance due of $15. I explained that I paid it at my last visit, and had returned my bill with a note to that effect, and reiterated that I did not owe the $15. The receptionist spoke to the office manager, who then explained to me that I had paid the co-pay for the annual exam, but owed the co-pay for the diagnostic sick visit. I was puzzled, thought she was incorrect, and told her that I was not going to pay the bill but would contact my insurance carrier about it.
“That doesn’t seem right.”
When I got home, I pulled out my EOB (explanation of benefits) and closely examined it. I saw the following charges had been submitted by the doctor: $150 for routine exam, $10 for speciman handling, and $115 for office visit.
I called my insurance carrier and explained the situation to them. The first person said, “That doesn’t seem right,” and asked if I had been to the doctor twice that day. No, it was one visit. She said she would escalate it to a supervisor for review. I updated the doctor’s office to let them know I was still investigating and what the insurance company was doing.
I got a call back from the office manager. She said, “I don’t know what your problem is.” (Nice customer service.) She went on to remind me that my appointment was for my annual exam, which only included a breast exam and pap smear. I should remember, she said, that the doctor could have let me go home and just scheduled me for another appointment. But, instead, he allowed me to discuss my health issues with him at that time because it was more convenient for me since I was already there.
Funny, I thought that the purpose of an annual exam was to be able to discuss my health issues with my doctor.
“I agree with you, it’s not right. But, it’s legal.”
A couple days later, I got a call from the billing company hired by the physician’s office. Apparently, the office manager asked them to call me about the billing. A much more pleasant woman explained to me that the billing was accurate. The “well” visit (annual exam) and “sick” visit (discussion of menstrual problems) portions of my exam are legally allowed to be billed with separate billing codes, separate charges, and therefore separate co-pays are due. She was very sympathetic, even to the point of telling me that she would ask the same questions I was asking. She acknowledged that it just didn’t seem right, but it was legal.
Legally right vs. morally right
It seemed that everyone involved was acting within the bounds of the rules in place. I didn’t really have any other options, so I sent my $15 check to my doctor, with a little note that said the following:
“These charges may be legally right, but they are morally wrong.”
It was only $15. But the principle behind the extra charges is what is wrong with the system. At an annual exam, a patient should be able to discuss health issues without the insurance carrier being billed an extra $115, and without the patient having to pay another co-pay. Multiply this by the hundreds of thousands, perhaps even millions, of other women discussing health issues at an annual exam. That adds up to a lot of money.
healthnation.com
It was ONE doctor visit. However, according to the rules in place, when my doctor asked me a question about my health and I answered with anything other than “Everything’s fine,” the appointment was considered to be BOTH an annual exam AND a sick visit.
Something is wrong. Reform is needed.
What are your thoughts? Have you had a similar experience? Or, perhaps you have another story that illustrates the need for reform?
Leave a comment and share your story.
My response? If he believes in me, I should too! I’m going to Chicago and taking the lead on this one! I’m sure it will be fine. My nervousness will help me prepare far better than if I weren’t worried at all. As Drew Brees said above, perhaps that nervousness will actually give me an edge. Or, like Stevie Nicks, will the fear lead to a magical experience?
The 
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