Billing a Trivial Case

My teenage son presented at a local hospital-affiliated express care clinic complaining of a persistent sore throat. The nurse examined him and ordered a throat culture to test for strep.

He was sent home with no prescriptions, only instructions to get rest. It seems to have been a mild case. Indeed, we heard a few days later that the culture did not indicate strep.

We subsequently received charges for $361, adjusted to $254 (after a $107 adjustment) and further discounted to $203 if paid within 30 days. Some weeks later we received a statement with an outstanding balance of $354, adjusted to $268 after insurance, related to the same service date; it’s not unusual for balances to move as insurance claims are collected and processed. We believed these charges were on the high side for a sore throat examination, but we paid the $268 amount

Four months later, we received notice from a collection agency that charges for $254 were due. We tried to reconcile the charges, but were sent back and forth between the facility and the physicians group. Upon closer inspection, the first charges, $361, were facility charges, and the second, $354, were professional fees (the nurse). This means the total amount for a sore throat examination totals $715 less a $107 adjustment. That is $608.

This billing practice was unexpected for a walk-in clinic. The amounts are astonishing.

We tried to get the procedure (CPT) codes from the clinic, but they would not provide those over the phone; they will send by US Post. We also asked that these charges be reviewed, which they agreed to do. We called our payer and asked for the procedure codes. They outlined professional charges (CPT 99204) for examination and management (E&M) for a new patient comprising: 1) comprehensive history 2) comprehensive exam and 3) medical decision-making of “moderate” complexity. Interestingly, the facility charges were treated differently (CPT 99213) which is E&M for an existing patient and the three components outlined immediately above, but for medical decision making of “low” complexity.

We appear to have a case of marketing an express clinic as a retail site for minor injuries, illnesses, and treatments, but billing with in-patient methods and rates. We also appear to have up-coding practices in play. My son’s condition should have been CPT 99212 (existing patient, and “straightforward” medical management) which would have been approximately $66 (facility + lab fees) instead of the $362.

We filed a complaint with our payer so they have some market feedback to negotiate rates next year.

It is not only a fee-for-service billing practice (and dubious coding culture to match) that brings us to a $608 sore throat examination. It is also a lack of consumer engagement, i.e., I should have shopped around first. But even that has its limitations… cost estimators provide only average claims expenses; it is quite difficult to get specific prices for specific sites. Estimators would not have foretold the billing complication of professional AND facility fees. Using payer cost estimators as well as exploring price lists at retail sites (CVS, Walgreens) is necessary, but time consuming.

For this case, the most obvious conclusions: 1) skip the visit altogether 2) skip the hospital-affiliated clinics, 3) shop around when possible, and 4) carefully inspect the medical bills and insist on the details.

So this is for a straightforward, trivial, condition. Consider the millions upon millions of people suffering from chronic or life threatening conditions showing up at emergency rooms thus beginning an endless episode of healthcare pinball. It is not a wonder so many face medical bankruptcies, and what must be a feeling of utter helplessness.

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