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Linda
Brandwin, R.N.
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Linda
Brandwin
is a registered nurse and a medical billing
and claims specialist. For the past 10 years
she has worked directly with insurance companies
to give advice and guidance to the health care
consumer.
Readers may send email
or write Linda Brandwin at 5500 Single Oak Hill
Ct., Woodbridge, VA 22192.
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Some
doctors choose not to participate in medical insurance
Feb. 27, 2004
Q:
I
am going to a specialist for treatment for a medical
condition I have had for several years. He does not
accept my insurance. His bills are five hundred dollars
for an office visit which lasts about twenty minutes.
I am much better and he is the only physician that has
been able to help me. He has even written articles about
my particular condition. He says his bills are high
because he is one of only about ten doctors in the country
that has been trained to treat my illness and this treatment
is highly specialized. Can a doctor legally charge these
amounts?
A:
A
doctor can charge whatever amount he wishes. If the
doctor participates with an insurance company, he will
only receive what the insurance company allows. If he
is not a provider with any insurance companies, he will
obviously receive full payment for his services.
Most
physicians base these charges on competitive rates of
their fellow physicians in surrounding locations. They
know what the market bears and what the average charges
are in their specialty field. If you see a dress in
store A that sells for $100, and then you see the identical
dress in store B and it sells for $500, it doesn't take
much to figure out where you will buy the dress. The
same theory holds true for physicians and they are aware
of this.
There
are five different levels of office visits. These levels
range from the least complicated visits to visits that
require a high level of medical decision making based
on a more complex evaluation and management of your
condition. Usually, not always, the more complicated
an office visit, the longer it will take. Office visits
have to meet certain criteria. These criteria are about
the patient and his problems, not about the training
and skill of the physician. Insurance companies, including
Medicare, will not pay extra for an office visit if
a doctor has special training to handle a particular
condition or if he has written articles.
Your
doctor does not belong to your insurance company. If
he did, his reimbursement would not be anywhere close
to what he is charging you. I don't know why he is charging
you so much. He knows the reimbursement requirements
of office visits and knows that extra training does
not warrant increased payments. You will have to decide
if the money is worth it. If you have trust and confidence
in your doctor and are being successfully treated, then
you might decide he is worth every penny. Or you could
make some phone calls to physicians that are part of
your insurance plan and question them as to your condition
and how they would treat you. Your local hospitals may
also direct you to some physicians who may be able to
treat your condition. Even if some of these doctors
are not part of your insurance plan, they may still
be considerably cheaper than the doctor you are currently
seeing. Some comparison shopping may prove to be enlightening.
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