My doctor's office sent a bill in the mail recently, recapping the costs from the first visit with my new endocrinologist here in Michigan.
Instead of a nice little co-pay amount, a whopping $271 total screamed from the statement and delivered what felt like a punch to the gut.
Thanks to new insurance that began mid-year, I haven't yet met my high yearly deductible. That means I don't get the benefit of a simple co-pay for each doctor visit. This is the 8th endo I've seen in my three decades with type 1 diabetes, and this is the highest bill I've ever been sent for a single office visit!
My head, heart, and wallet were hurting. It made me cringe, having to once again accept not only the high cost of healthcare overall, but also these high fees charged for an initial appointment.
As a refresher, I'm now seeing the well-known Dr. George Grunberger (Dr. G) after moving back to this state over the summer. As any new patient appointment goes, we spent most of that first visit in August covering basics and figuring out where to go next with my D-management.
As I reported last month, what definitely raised my eyebrows was the fee schedule that Dr. G has posted in his office: a $5 processing charge for calling in a prescription; $10 for obtaining blood sugar logs or lab documents; and $25 for a pre-authorization letter to insurance or a form letter for traveling. These "physician services" seem like basic parts of the job -- but I tried to keep an open mind about how overworked many practices are, and the fact that these fees are often used as reminders to patients (i.e. they can sometimes be waived if patients are proactive and call ahead).
But once my first bill arrived, I felt my blood pressure skyrocketing, as I scanned the statement over and over.
I started wondering what it would be like if I, as a patient, could bill my endo for charges related to his care.
So, I've penned my own "Patient Services Bill," below. (Naturally this is a tongue-in-cheek way to vent my frustrations.)
Statement for Patient Services to Physician
Prescription Filling: $85
Every endo I've ever seen has been willing to call in my prescriptions to the local pharmacy, or give me a written Rx slip to take in myself, even if it's not the day of my appointment (because sometimes life happens and you need a refill on the fly, or you want to try a new medication before the next visit three months down the road.)
This happened after my August appointment. I wanted to try a new medication, and with all the "new patient excitement" that day, I forgot to ask about this. So I called soon thereafter, and left a message. My new doctor's office didn't return the call until over a week later, by which time I had found a new pharmacy and needed to have all my prescriptions sent there.
It was like pulling teeth, to convince you that it would make more sense for you (new Dr's office) to do this rather than the previous pharmacy I had used, as they would only be calling you anyway to ask what Rx's are needed. See, they don't know me or have a medical file on me. You do. This is part of your job!
It takes time to phone your office, explain my Rx needs, and then to navigate between your office and the pharmacy or vendor filling the order.
After my initial call on Sept. 8, I waited a full eight business days for a response. I hereby bill you at a rate of $10/day, as well as a $5 surcharge because your office closes at 2pm on Fridays, requiring me to adjust my work schedule if I need to see or communicate with you.
Diabetes Device Fee: $20
You charge a fee for reviewing my device data. That is only fair. But I also carry the burden of bringing in my device, loaded with meaningful data. My rate for that is $10 per device, a considerable discount from the $85 you ended up charging me to download and review my CGM data alone. Believe me, we patients spend more time reviewing our data each day than you do in that 30-minute window, so we should be compensated for data interpretation too.
Provider's Online Records Portal: $10
You required me to use your provider-optimized online system, Patient Fusion. I'll admit it was cool to see all my info there online, even if I did need to take time to learn this system... But then, after our first appointment alone, I received seven emails from Patient Fusion, plus a survey about our initial visit. This required time out of my workday to register, log in, and and review the content. I hereby assess a $10 fee for this, just as you charge for downloading and reviewing my data and interpreting my lab work.
Lost CGM Data Reimbursement: 26 cents
When you take my Dexcom away from me, that means it's out of range while you're off downloading data to review. In this case it was a nearly 30-minute interval, for which I hereby charge you. How did I calculate the cost? It's D-Math: My monthly cost of a box of four G4 sensors, divided by 4, divided by the FDA-dictated 7 days of wear, times the number of minutes you had my Dexcom in quarantine. This one's not a lot of money, but I want it back.
Phone Tag/Aggravation Service Charge : $1.01
We exchanged no less than 9 phone calls related to my care between my first and second appointments. A majority of those were return calls to me, as you (the practice) didn't have ready answers to my questions so had to follow up yet another day.
Most recently, I phoned your office to ask about a $10 charge on my bill that I didn't understand. Nope, I had to call a billing service instead. That person read the fee off the bill to me, but couldn't explain what it was actually for. So, an account manager would need to investigate and return my call. This took another two days.
Each month, I spend $50.82 for my business phone line. These doctor calls* totaled roughly 2% of my time during the past month; the IRS allows for 2% reimbursement.
* No extra surcharge is being assessed for the non-returned calls, or 24+ hour waiting periods when I was left hanging with anticipation.
Marketing and Publicity: $50
See this blog post on 9/16/15 at DiabetesMine, entitled: "My First Visit with a New But Familiar Endo"? Although my intention wasn't really to plug you (but just to share my real-world patient experiences), I am now reconsidering billing this to you as marketing, good will publicity, and awareness-raising PR for important diabetes issues.
Please refer specifically to the positive references to Dr. Grunberger, his role as president of the AACE, and larger discussion about endo reimbursement.
I equate this to the standard $50 you charge for a personalized letter detailing my medical necessities, for me to use while traveling.
Total Charges: $166.01
Empowered Patient Discount = 50%
Amount Due By Physician: $83
Please note: insurance coverage and CMS reimbursement may vary. In order to ensure prompt service and responsiveness, please have your payment ready at time of office visit, prior to any patient payment of co-pays or co-insurance fees. Thank you for understanding.
- The Diabetes Headquarters of Michael Hoskins, Type 1 since 1984 -
My Endo's Office Should Be Like a Car Repair Shop
OK, I had fun compiling the above, and didn't really intend to confront my doctor with it...
But then, I got to thinking that seeing my doctor for a "diabetes tune-up" should be like going to a mechanic to have them check your vehicle; you should be able to get a rundown of all the proposed services and costs and be able to choose what work you want done, and don't.
If you're at least offered a package plan that includes many services for one combined fee, it's not as big a deal. The problem is, being nickle and dimed on all these disparate fees, by both the doctor's office AND the insurance plan. Is it not possible for me to pick and choose?
I decided to test this out during my second appointment on Oct. 1, by refusing to let his office download my device data.
Of course I entered his office with my three D-devices -- Dexcom G4, Medtronic insulin pump, and Bayer Contour Next glucose meter -- the most critical being my CGM that has all kinds of important glucose trend data. It's also the most costly to analyze.
I had since learned that my insurance plan stipulates Dr. G can't get reimbursed more than $18.05 for CGM data review. That means I am responsible for anything over that amount. Since he charges $85 for this service, I knew I would have to pay $66.95 if he did the full CGM oil change, so to speak.
Instead, I offered to give Dr. G my own view on recent glucose trends -- especially as it relates to higher morning BGs and possible dinner-time meal bolus concerns. I read off my data from a piece of paper, informing him of trends and BG averages that I observed.
Of course, he asked why I wouldn't allow the device download.
"I want to avoid the $85 fee you charge for CGM data review."
Both he and his endocrine fellow looked at me, dumbfounded.
Dr. G shook his head and said, "C'mon, I'm not clairvoyant, man!"
Bargaining, I offered to let him download my device data, but only give me $18.05 worth of his opinion -- since that's the contracted rate my insurance allows for this particular billing code.
He wasn't amused, but we were able to talk out my BG issues (as explained to him by me) and make some good changes.
The Business of Diabetes Care
I know it may sound like Dr. G is more fee-happy than other doctors (and maybe he is, a bit), but I'd put money on the fact that ALL of us are being charged fees for this stuff, baked into the bills we get.
And yes, I do value the insight and experience of a trained medical professional who probably has some very good advice to offer me.
At the same time, what about patient autonomy?
I have to pay a lot of money to manage my diabetes adequately, so why can't I choose what services may or may not be worth the extra cost during an endo visit?
It's a business being an endo, I get that. Well, hell. It's a business being a patient too.
What I'm saying is that providing healthcare, and diabetes expertise, isn't easy and it's not cheap It takes time, energy, and money -- just as it does to live with these chronic illnesses. There needs to be a balance...
Meaning, if there's anything that needs to be fixed in our messed-up healthcare system, it's creating a structure where doctors aren't forced to break the bank and lose money to do the simplest parts of their jobs -- but also where we patients aren't being forced to foot the bill on multiple charges for things that may not actually be needed.
We have to meet halfway on this, and that's just the kind of process innovation we are hoping to see emerge in this exciting time of healthcare upheaval. There's no charge for keeping our fingers crossed, thankfully.