Legal Question in Health Care Law in Georgia

My healthcare Health Reimbursement Account (HRA) is set up so that if you get a physical, not only are you not charged for the physical, but money is put INTO your account. They encourage everyone to get a physical once a year and give you this incentive to do so. So, I made an appointment for a physical. Prior to the physical, I called the insurance company and got a list of the codes that are used when having a physical so that I could give it to the dr. office to make sure the physical was coded correctly (it had been suggested to do so b/c so many offices get the coding wrong). I went to get my physical. The doctor did the standard physical, physical bloodwork, etc. and found fluid behind my ears and found a tender spot on my abdomen that she said might be gall stones. She said I should try flonase to help with the fluid in my ear and that if the tender area ever started to hurt, that I should come in for an ultra sound. I also recieved a prescription for prenatal vitamins. Weeks later, I recieve bills for the visit and find out that the visit was coded as an office visit and not a physical b/c I was treated for conditions. I did not go to the doctor b/c my abdomen hurt (it only hurt when she pressed on it) and I did not go b/c my ear hurt, she found the fluid as part of the physical. The doctors office REFUSES to change the coding of the visit, said it is illegal for them to do so and said if I want to talk to the doctor about the way it was coded, I would have to have an office visit (another charge). So, since the physical found 'problems' it was changed from a physical into an office visit. The other problem with this is that b/c they changed the coding to an office visit, all the physical bloodwork that was done is now also not covered under a physical like it would have been had they coded it correctly and I am having to pay for that too! And on top of all of this, I still have to go in for another physical in order to meet the requirment for my HRA account! Is there anything I can do about this?


Asked on 8/16/10, 2:21 pm

1 Answer from Attorneys
Phillip M. Cook Cook Legal Services, LLC

I'm sorry to hear you are stuck in this situation. It sounds as though you are caught in the middle of your employer, insurance company, and a doctor you barely know. Since the doctor's billing department won't assist you in correcting the problem, I would consider taking the following action:

1.) Schedule a follow-up appointment with the doctor and speak to the doctor directly/in-person. She is the boss and can make decisions effecting her practice! Bring your spouse, significant other, family member, or a friend with you if you are hesitant to go on your own. POLITELY explain the situation to the doctor. The doctor will likely be embarrassed that this situation happened and correct it. If the doctor refuses to change her coding, explain to her that you will have to file a complaint with the State medical board, your insurance company, and your employer. If the doctor attempts to charge you for the second visit as well, ask for a written bill and politely refuse to pay at that time -- you have not received medical treatment/attention.

2.) If the doctor's office is not willing to correct the problem, you should immediately speak with your company HR rep (and follow up with a written letter or email confirmation of your conversation) and simultaneously report the issue in writing to your insurance company. If this doctor is not willing to play ball, your employer and insurance company need to be made aware so that the problem does not continue.

Since you will have to get yet another physical to meet the requirements of your HRA account (sorry!), it would not be inappropriate to ask your employer to cover the out-of-pocket cost and pay you the HRA incentive as well. Your employer may refuse, and you may consider letting it go at that point, but it never hurts to ask, especially under the circumstances. You may also consider reporting the doctor to the Georgia Medical Board and let them decide if what the doctor is doing is ethical under their standards and guidelines. Information on filing a complaint is located at http://medicalboard.georgia.gov/portal/site/GCMB/menuitem.2f54fa407984c51e93f35eead03036a0/?vgnextoid=76e11ec599906210VgnVCM100000bf01020aRCRD.

3.) If 1 or 2 above do not get you relief, you may consider hiring a Georgia attorney to represent you.

Best of luck. ******The above does not establish an attorney-client relationship and is intended for informational purposes only.******

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Answered on 8/22/10, 3:41 am


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