One of the most frequently asked questions we have when patients walk into our clinic is “How much will today’s visit cost?” This is often difficult to answer and many patients do not understand why. After all, prices for many services are typically known in advance of services being rendered. Car mechanics give quotes before servicing your car, attorneys quote an hourly rate, so why is it difficult for an urgent care to tell you what your visit will cost?
The answer to this question lies in the complexities of medical billing and coding.
When you are seen at an urgent care, or any other medical office, your visit will be billed using a set of codes known as evaluation and management codes. These code sets are based on five different levels of service, with one being the lowest level of service and five being the highest. These levels are determined by criteria outlined by the American Medical Association, which has broken down this criterion into three areas: History, Exam and Medical Decision Making.
The patient history documents the history of present illness, a review of symptoms, and the patient’s past, family, and social history. The exam is the doctor’s notes detailing the areas and symptoms that are assessed. Medical decision making is the third criterion and is an overall analysis of the patient’s visit. Medical decision making looks at the present problems, the procedures, clinical labs or other tests performed, and the risks involved with the patient. Each of these three areas of information and assessment are aggregated to determine in which of the five levels of service your visit will be billed. In summary, the History, Exam, and Medical Decision Making are methods to quantify the time and effort of the doctor and are done in much the same way as other professionals charging more as a result of more time, expertise and services.
In addition to the medical receptionist being unaware at the time of check-in which level of office visit the doctor will charge, it is also hard to determine if additional tests will be needed. For example, if a patient comes in with a painful ankle after it was twisted while snowboarding and also has complaints of a sore throat, it is hard to know right then if the doctor will want to do an X-ray and/or a Strep test. A good doctor will always try to avoid radiation exposure or unnecessary tests if at all possible.
So now you’re saying “Okay. I get it. It’s complicated. So what can I do?” Here’s what I would recommend:
– Ask what the typical level of service is for a new patient and what it costs. Most urgent care facilities’ patients receive a level three or four service.
– If you have been to the facility at least once in the last three years, you are considered an existing patient, if not you are considered a new patient. Office visits for existing patients will cost less. Be sure to ask what the charge difference is for being a new or existing patient.
– If additional labs, X-rays, injections or procedures are ordered, feel free to ask the nurse or medical assistant what these could cost.
Most importantly, if you have health insurance, please understand your policy. Do you have a co-pay? Do you have a deductible? Is the facility contracted with your insurance? Is there co-insurance? Do you have secondary insurance?
On this topic, understanding your insurance will be helpful in knowing the real costs to you as a patient. What offices charge and what you actually end up paying may be quite different. Keep this in mind when getting those charges for office visits and tests; they may be just a fraction of the cost that will be charged. If you’re asking why this is, stay tuned for my article next month. FBN
Alex Conrad, CPC
Business Manager
Troyer Urgent Care, Inc.