UninsuredinAmerica.org

Dr. Stephen Blythe

What is an “office visit”, anyway?

The federal government, because of the costs of the Medicare and Medicaid programs, is very interested in defining and clarifying what constitutes an "office visit". You can imagine that an office visit to look at a child’s rash and prescribe an appropriate lotion or cream is a lot different than an office visit to evaluate an older diabetic with shortness of breath. An office visit is considered a class of visit called “Evaluation and Management Services”, or E&M Services. Office visits are separated into five general classes. These classes are distinguished based on their complexity. They may be distinguished based on time spent, but only if over half of the time is spent not in clinical evaluation and management but in counseling and/or educating the patient. So an office visit for the diabetic with chest pain will be based on the complexity of the patient and the problem, not determined by time spent. Whereas a visit with a diabetic which is mostly spent educating them about diet and exercise and how to adjust their insulin dose may have no actual evaluation involved, but will be based on time.

The five levels of office visits are as follows, separated for new and established patients. The estimated time involved gives a rough idea, but remember - time is not a factor in determining which level of service is provided unless most of the visit is spent counseling or educating the patient about their condition.

Office Visit Type:

New or established patient estimated time required and Medicare payment.*

Example Problem:

Level 1

   10min/10min

$36.56/$35.49

Single simple problem – rash, bladder infection, scrape or minor cut requiring no treatment.

Level 2

  20min/15min

$61.07/$58.60

Routine problem: respiratory infection or a simple problem requiring extra testing – a minor injury requiring an x-ray, for example.

Level 3

  30min/25min

$90.02/$88.27

Several routine problems or a single problem requiring multiple testing, such as abdominal pain with blood tests and x-rays needed.

Level 4

  45min/40min

$137.30/$119.75

Complicated or poorly controlled problem requiring extensive examination, history-taking, and testing or several problems each requiring extensive evaluation. A diabetic patient with intermittent chest pain, for example.

Level 5

      60min

$172.58

Unclear distinction between a Level 4 and Level 5 visit for an established patient.

A new patient with a complicated problem or problems which requires also detailed review of history, past records, etc.

* Medicare Central Florida 2009 Fee Schedule

There can be overlap in these visit definitions, but clearly there are times when it is obvious that a visit is not correctly charged. I have had patients tell me that they were charged for a level 5 visit when they went for the simple five-minute visit to the GI doctor to discuss their upcoming screening colonoscopy. And yet no detailed physical examination, history taking, or decision-making was performed in relation to that visit. Insurance companies – including Medicare and Medicaid – will routinely evaluate physician practices to see what percentage of visits fall into which category. A physician who is billing far more Level 4 and 5 visits than their peers might undergo a chart audit, and sometimes is required to reimburse the insurance company under threat of criminal fraud charges.  The cash-paying patient doesn't have that option, and can only ask questions about billing before and at the time of service.

 The above list will let you know if the charges you are getting hit with are way out of line with reality. Some insurance contracts pay physicians 20% or so above what Medicare pays, so if an office offers to accept payment at time of service for 20% above Medicare, that is still not too bad for you, and an excellent business practice for them, since they do not have to mess with any billing and collections. Some offices are reasonable with cash patients, but there are specialists in my area that charge $420 for a new patient complex office visit. This is about twice what they get from any insurance company for the same Level 5 visit, and, I feel, is inappropriate. In my office, we charge “Medicare-based” fees to our cash patients – this essentially means that we round off, so that a Level 2 visit would be charged at $60. Although if I know someone is in financial hard times, I am much more likely to give them a $10 or $20 discount as well. 

 One way to negotiate with a physician’s office over the prices that you will be charged is to call before your visit and ask to speak to the office manager. Ask them if they will accept Medicare fees if you pay at the time of the office visit with cash or credit card. Many offices will agree to this arrangement. If they balk, ask them specifically what percentage above Medicare rates they will charge you – since few insurance companies pay more than 20% above Medicare rates, your physician should be happy to receive the same in cash (or credit card)! Bring the above list of office visits as a general, but not exact reference. It will give you an idea of what range you should be dealing with. Again, remember that the time periods mentioned above are crude indicators and that the visit cost is NOT determined by time spent unless at least half the time is spent counseling and/or educating.  During a forty minute visit with an established patient to discuss their family stresses and treatment options for their depression, I may never lay a hand or stethoscope on the patient – but it is still a Level 4 office visit.