ala carte medical billing, billing type notification.

[Altairah]

What is the name of your state? OR

I'm writing this on behalf of my Godmother. She recently switched both insurance and primary physicians. Her new insurance provides up to $1000.00 dollars a month to cover all medical costs(visits, prescriptions, etc.). After that, all expenses are the patient's responsibility.
Her new doctor informed her of his standard office visit cost when she first started seeing him. However, it seems he actually bills "ala carte" for separate consultations, topics of discussion, etc., within each visit.
Without notifying her of these additional charges, he used up her entire coverage amount for the month in just two 40 minute visits, including the first "new patient" visit.

Question #1: Is this legal/ethical/heard of?

She now faces urgency care and prescription charges incurred in that month.

Question #2: Does she have any recourse to take with her insurance company? (either against the doctor, or to force payment by the insurer)

Thank you for your time.

 

[lealea1005]

What is the name of your state? OR

I'm writing this on behalf of my Godmother. She recently switched both insurance and primary physicians. Her new insurance provides up to $1000.00 dollars a month to cover all medical costs(visits, prescriptions, etc.). After that, all expenses are the patient's responsibility.
Her new doctor informed her of his standard office visit cost when she first started seeing him. However, it seems he actually bills "ala carte" for separate consultations, topics of discussion, etc., within each visit.
Without notifying her of these additional charges, he used up her entire coverage amount for the month in just two 40 minute visits, including the first "new patient" visit.

Question #1: Is this legal/ethical/heard of?

She now faces urgency care and prescription charges incurred in that month.

Question #2: Does she have any recourse to take with her insurance company? (either against the doctor, or to force payment by the insurer)

Thank you for your time.

Each of your godmother's medical problems (example: high blood pressure, diabetes, high cholesterol) will have a separate diagnosis code. Each type of office visit, venipuncture, laboratory service, EKG, etc., will have a separate procedure code called a CPT code. The Physician is obligated to code the claim properly for submission to the insurance company.

"Standard" office visits, in medical office speak, are for simple problem focused issues (medication checks, sore throats, colds, etc.). Perhaps your godmother presented with symptoms that required attention by the Physician that was beyond the "standard" office visit. Since it was her first visit, he may have taken an extensive history, reviewed her medications, ran a few diagnostic tests. Depending upon her medical problems, it would be well within the standard of care.

Hope this helps. Without looking at the codes on the bill, it's hard to say more. Perhaps others will have additional information for you.

 

[ecmst12]

Yes, that is totally normal. Every service that the doctor provides will have a separate charge. New patient visits especially take more time and therefore cost more. It's totally normal and expected, the doctor is not doing anything wrong, and if that's her insurance plan, strange as it may be, there's not a way to make them pay more then they are legally obligated to pay.