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On the Third Hand: Bad Consumer

By Allison Bell

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I think anyone who cares about the overall health of the U.S. population has a stake in keeping routine medical checkups from turning into a diagnostic coding battleground.

That hit me a couple of weeks back as I was reading a great Associated Press article about primary care doctors coding checkups as sick visits, and, simultaneously, looking at the explanation of benefits Web notices for my own checkup.

The doctor upcoded the checkup to a sick visit without warning and turned what was supposed to be a visit with no out-of-pocket costs into a visit that was going to cost me $400 out-of-pocket.

Anyone reading this who’s involved with processing or analyzing claims for a health insurance company is now laughing at me. The dirty, mostly forgotten secret about why doctors have to deal with so much insurance company red tape is that doctors brought the red tape on themselves by being a bunch of greedy thieves back in the 1980s.

Doctors and hospital executives love to complain about how health insurance companies surely are responsible for the fact that U.S. health care costs are double or triple what they are in Europe.

What the white coated ones do not usually mention is that, when expressed as a percentage of gross domestic product, the gap between U.S. health care costs and health care costs in other rich countries bounced between about 25% and 35% from 1960 to 1980.

The gap ballooned from about 35% to more than 80% from 1980 to 1992 and has been seesawing up and down between 75% and 86% ever since.

One possible explanation for the widening of the gap in the 1980s may be that that’s when physicians started to turn upcoding of patient visit diagnostic codes into a blood sport.

Of course, anyone who’s reading this and loves health savings accounts (HSAs) is also laughing at me because they already have guessed, correctly, that I’m taking the upcoding as personally as I have because I have an HSA.

If the doctor had just charged my health insurance company some absurdly high level, and the insurance company had used the network provider agreement to knock the amount actually paid to some absurdly low level, I would have just laughed and mused ruefully about the brutality of payer-on-provider warfare.

Because my puny little HSA is in the game, I’m not musing. I find that I’m calling the doctor’s office and trying really hard to figure out where the line is between me expressing justifiable anger and folks in white coats carting me off to a secure inpatient facility. I think I’ve won. The receptionist at the doctor’s office says the biller will resubmit the claim “soon.” But does that really mean the biller will resubmit the claim soon, or is that kind of statement akin to, “The check is in the mail,” or “I’m from the government and I’m here to help you”?

This incident could make a nice episode in a funny new reality TV show, “Claim Wars,” but, in the long run, if many patients find that “free” checkups are part of a bait-and-switch swindle, the results could be that many patients might give up on the idea of trying to get checkups.

Aside, maybe, from life settlement providers and issuers of annuities without death benefit features, just about everyone in the LifeHealthPro community has an enormous stake in seeing that consumers get checkups. Life insurers, disability insurers, long-term care insurers, agents, brokers and public officials all know the well-being of the insurers, and maybe of the finances of the entire United States, depend in part on people getting their weight, blood pressure, blood sugar and cholesterol levels checked.

Commercial health insurers have recognized that reality by accepting the new preventive benefits provision in the Patient Protection and Affordable Care Act of 2010 (PPACA) relatively calmly. Carriers may not be thrilled that they have to cover tetanus shots and mammograms for eligible enrollees without imposing any cost-sharing requirements, and they may disagree with the U.S. Department of Health and Human Services about what exactly ought to be in the basic preventive benefits package, but no one is going to the Supreme Court to attack the constitutionality of the concept of the federal government requiring first-dollar coverage for mammograms.

Insurers and government agencies also depend on patients who do have bad numbers but feel fit as a fiddle taking their physicians’ advice seriously.

The science of wellness, meanwhile, is really in its infancy, and patients have to accept a great deal of advice about dealing with bad numbers — advice that may lead to big, unpleasant changes in lifestyle — on faith.

It’s easy to that “everyone knows being fat is bad for you,” but it’s not so easy for someone who likes cherry pie to give up cherry pie. Patients, meanwhile, have heard that drug companies pay researchers to come up with studies that make so-so drugs look less potential harmful and more potentially helpful than they really are. And patients know that, in most cases, the most serious ill effects of having bad numbers are likely to come years, or decades, in the future. Many people with bad numbers can name a long list of close blood relatives who lived into their 90s with lousy numbers, while the doctors with good numbers who kept nagging them died in their 70s.

My initial reaction to finding out that my cholesterol numbers were going the wrong way was relatively mild. I thought, “I’d like to try to diet really, really hard for a few months and see what that does before taking a pill.”

The doctor recommended one of the low-carb diets. There’s an app for that, and I’ve been a good, fanatical, lettuce-leaf weighing low-carb dieter.

But, once I realized that my “free” checkup was on track to cost me $400 out of pocket, because of fraud or a very convenient error, one of my reactions was, “Well, that’s the last time I’m getting a checkup till the health care system fixes checkup billing.”

In theory, health is wealthy, and a few hours of wrangling over a bill should’t stop me from getting checkups. In reality, the idea of putting up with hours of bickering to find out that I’m similar to my parents seems really off-putting.

My other reaction was to question the integrity of just about everything the doctor had told me. If he was going to upcode me in ways that would cost me $400, why wouldn’t he rip me off in other ways?

He recommended a brand-name low-carb diet and a brand-name cholesterol fighting drug. Well, is that because those are what’s best for me, or because the low-carb diet representative and the company that manufactures the cholesterol drug took him out for really nice dinners at the last medical conference he was at?

One of the benefits of getting a checkup is similar to a benefit one gets from voting or organizing one’s closet: The idea that the universe is saying, “Good consumer! Good, responsible consumer.”

The checkup upcoding problem turns the psychic benefit on its head. Instead of the universe saying, “Good consumer!”, the message is “Bad consumer! You’re an idiot for going to get a checkup in the first place. The next time you do something that stupid, why not cap it off by buying used car for the price on the window sticker, and celebrate by buying a timeshare for a condo on the Brooklyn Bridge?”