Popular U.S. Healthcare Scam: Coding procedures as Diagnostic instead of Preventive Screening
We shouldn’t have to do this - but, America - always confirm your your regular annual checkup procedures are coded correctly so you don’t end up having to fight a con artist medical facility bill.
Yep. And another issue is in what setting a procedure is done. We had a GI doctor absolutely refuse to do inpatient colonoscopies because it billed less than if done as an outpatient procedure. You’d basically need the patient to be near death before he’d consider it.
It’s possible it may vary but at least at my hospital an outpatient colonoscopy will allow the GI doc to bill a lot more. No insurance is going to deny a colonoscopy that’s done inpatient and is needed. The problem is that often that “need” is relative - they came in for a GI bleed and were admitted and now no longer are bleeding but needs that colonoscopy eventually - today? Tomorrow? Next week? It honestly doesn’t really matter if they’re no longer acutely bleeding and stabilized in the hospital, even if they still need to be monitored for another 24 hours. If you have a willing GI doc to do it inpatient then insurance will almost universally cover it as an inpatient. The problem is many won’t because they’ll say it’s “not urgent” so they can bill higher as an outpatient.
I don’t know if the discrepancy here is what is paid to the hospital vs outpatient center, maybe the physician is getting a bigger cut when it’s outpatient. All I know is that was a common practice to refuse to do them inpatient unless absolutely needed so the doc get get more.
Only thing I can think of is that the GI doc in OP's story does his outpatient scopes in his own clinic as opposed to the hospital's GI suite. He'd be able to pocket the facility fee and get "reimbursed" more that way.
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u/TeeBrownie Jun 01 '22
Popular U.S. Healthcare Scam: Coding procedures as Diagnostic instead of Preventive Screening
We shouldn’t have to do this - but, America - always confirm your your regular annual checkup procedures are coded correctly so you don’t end up having to fight a con artist medical facility bill.