The Benjamins

Contrary to popular belief, even if you don't have a co-pay up-front, you still may end up paying a chunk of your bill. So we get calls all the time from people who don't understand the concept of a deductible or percentage of cost, angry that we had the audacity to charge them for their visit (maybe I should be angry at my landlord for charging me office rent, huh?).

Blood work is also an issue. Several insurances, especially Medicare, have a whole list of diagnoses you need to have in order for them to pay for your labs. This list is hysterically obsolete and unrealistic.

Yeah. Like those.

I'm in the middle here. If I order too many labs, Medicare will claim they weren't necessary for the condition (in spite of a crapload of medical literature saying otherwise) and the patient will get cranky because OMG THEY HAD TO PAY FOR SOME OF THEM. But if I don't order all the labs I run the risk of missing something and getting sued over it. The defense of "the insurance won't pay for the test" is legally worthless in court.

So I order what I think is appropriate. I'd rather get yelled at by patients over their bill then roasted by a lawyer for malpractice. By ordering it, I put the ball in the patient's court. If they don't want to have the test, that's their decision. But at least I tried.

So what happens when you go to the lab? Before they draw blood, you sign a form saying that you agree to pay any charges your insurance doesn't cover (for the record, you do that at my office, too. And probably every doc's office. If you didn't know that you just haven't read the fine print).

Then, if you sign it, they'll do the labs and bill your insurance. It there's any left over, they'll bill that to you.

This is where things get iffy, especially with Medicare and their outdated list of tests that will only be paid for IF you have a certain condition.

Let's say, for example, that a Medicare patient is having a neuropathy work-up, and needs a vitamin B12 level done. Most docs order a B12 level. I  do, too sometimes, but generally prefer checking methylmalonic acid (MMA). Due to its role in B12's metabolic pathway, it's actually more sensitive for B12 deficiency than B12 itself. You can see a normal serum B12 in people who are metabolically deficient in it, but the MMA nails it.

I order the MMA level. Of course, Medicare, with guidelines written during the Nixon administration, doesn't recognize it as a valid part of a neuropathy work-up. Yeah, craploads of medical research since the late 80's say otherwise, but who am I to argue with the Medicare rule book?

"Damnit, Jim, I'm a doctor, not a Medicare desk jockey."

So I order the methylmalonic acid anyway. Why? Because my job is to correctly diagnose the patient.

The bill for the MMA level gets sent to insurance, where it's screened by some of the last functioning TRS-80's left on Earth. Their programming sees "MMA level ordered for neuropathy. Test not needed per our guidelines. REJECT!"

The lab doesn't get paid for the MMA. They'll now send me a note asking for any more diagnoses that might get it covered.

So, in my 15 seconds of free time each day, I crack open the chart and fill out the form with EVERYTHING the patient has (hypertension, migraines, halitosis, genital herpes, 1948 exposure to mumps) hoping one of them will somehow get it to pass through the TRS-80's scanning on the 2nd try.

Sometimes it does, and we all live happily ever after. Other times it doesn't, the patient gets a bill, and calls my office.

Now Annie will usually take a crack at it, calling the lab and consulting a Ouija Board to see if we can find anything else going on with the patient that might get it paid for. I sign off on it, and we submit it for the 3rd go-round. I'd say this works maybe half the time. The rest of them... the patient gets another bill.

Some people recognize that healthcare isn't free, and that I'm doing my best to care for them. They pay their bill. Others, however, go apeshit and call to scream at us.

They demand I find a way to make their insurance pay it, even if it means fraudulently changing the ICD codes (nope). Or that I pay it myself (nope). Some of them even threaten me:


"Get this paid for, OR ELSE!"

"If this isn't paid, I'm complaining to the state medical board."

 "This needs to be covered, or you'll hear from my lawyer."



Because now it's MY fault that I'm trying to provide decent care.

What's really irritating is that these same people screaming about me ordering a test they now don't want to pay for... would also be the first ones in line to sue me if I didn't order it and missed the correct diagnosis. I try to be thorough, and want to figure out what's wrong with you. Plus, in the sad calculus of modern medicine, my fear of being sued trumps your wallet every time.


My office's best attempts failed. Now what happens?

The patient, like everyone else out there with bills, has to either pay them or go to collections. I did my best to help. I'm not going to practice second-rate medicine and risk missing something. They don't have to get the tests, but once they've signed off on the lab form and had them drawn, it's their responsibility. Some of these labs are hundreds to even a few thousand dollars, and they're being asked to pay for, say, $89.46 on labs that totaled $1015.58 (yeah, that's from a recent one that crossed my desk). I'm going to point out that's less than 10% of the total charge.

If you go to Target for a ginormous $900 TV, and they sold it to you for $80, you'd be thrilled. But in medicine? You go bananas that it isn't free.

"$79.99, and it wasn't even Black Friday."

Once my two appeals to get it covered have failed, I'm done. I did my best. I also remind myself that, even if I do find a way to get you out of paying for them... it means everyone else (including me) is.

My sympathy on this issue has run out. I'm tired of people demanding I care for them, then not wanting to pay their fair share of the costs. If I DIDN'T order these tests, and missed something, they'd come back and sue me. But if I do order them they whine.

My view has become it's their decision to have them or not. It's a tax deduction if they want to see it that way, but healthcare is NOT FREE. Someone is paying for it, even if it's not the patient. Everything that gets covered by insurance is passed on to the rest of us in the form of higher co-pays and premiums.

Providing competent medical care is not something you can sometimes do well and other times do a half-assed job on. You either go big or go home, so I choose to go big. The same applies to the patient. If you want an incomplete work-up, that's fine, but don't go wailing when something was missed because you refused testing. By the same token don't expect quality care to be free.

You get what you pay for.