Give Your Doctor The Checkup
J. Greene

Q: What can a person do about a doctor who put the wrong information in the patient’s records, which caused the insurance company to refuse to pay? I made an appointment for my husband for heartburn and constipation, but the doctor thought it was a yearly checkup and put that on the chart. Our insurance won’t pay for yearly checkups. The staff in the doctor’s office says they can’t change it because it’s already in the records.

A: If your doctor wanted to change the records to reflect a more accurate depiction of what happened during your husband’s office visit, he could do that with no problem. You just have to hold your ground and demand that the change be made.

      The problem comes in, however, if there's a difference of opinion about what actually went on in the doctor's office that day. There can be a lot of confusion caused when a patient shows up with a minor complaint and then ends up getting a complete physical. The doctor is focusing on your health, not on whether he's doing something that your insurance will pay for. He may not be worrying at that moment about whether your insurance is going to cover a complete physical exam. It's up to you to understand your coverage and also find out from your doctor exactly what he's going to do during that office visit, advises Lynn Northcut Gregor, a consultant who specializes in medical billing.
What may have happened in this instance, Gregor notes, was that your husband came in for his heartburn but the doctor then asked some more questions and ended up giving him a comprehensive exam. What might have been more helpful, she says, is if the doctor had split up the coding to be more explicit about what actually happened during the exam: one code for heartburn treatment and another for the physical. That way at least part of the visit would have been covered by insurance, and it would be clear exactly what services were rendered. The doctor also should have gotten clear permission to conduct a physical exam. Of course, it's important for a patient to walk in armed with knowledge about what his insurance policy covers, so he can decide whether he can afford the fee for a physical if it's not covered.
      This brings up a couple of points that are worth repeating to ensure you remain an informed and empowered consumer of health care:

  1. Learn to talk to your doctor. Probably the biggest complaint most people have about their health care is their relationship with their doctor: Office visits are too short and the physician is in such a rush to get on to the next patient that it's easy to forget to ask important follow-up questions. The financial pressures on doctors aren't going to go away, so the only way to get more out of the encounter is to be firm in pressing your physician for clear answers to clear questions. Make a written list of questions ahead of time if that helps, and don't be afraid to call back later if you think of pertinent questions once you get home.
  2. Keep track of your bills. When you get a bill from the doctor or a statement from the insurance company, look over it carefully to see exactly what it says. Often, the first bill from the doctor's office won't seek payment from you, but will tell you how much your insurance company is being billed. And once you get the insurer's statement, carefully go over the codes attached to any denials so you understand why a particular payment was rejected. Billing mistakes are common, and it's up to you to catch them.


Here's another question about paying for a mistake at the doctor's office:


Q: Our daughter had a root canal done on the wrong tooth; the dentist admits this, but says the follow-up work with the post and crown was done by his partner. Our insurance is saying that the second dentist is not responsible for the error so we must pay. Since they are in the same office, why am I expected to put out several hundred dollars to get a crown put on a tooth that was perfectly fine?

A: Good question. And according to patient advocate Vincent Riccardi, you shouldn’t have to pay when a health-care provider makes a mistake. “I would insist that the dentist pay for it,” Riccardi says. “When you do something wrong (in medicine) you don’t expect to get payment for it.

      It's too bad that your insurance company is actually caving in on this one, but even so, try arguing with the dentist's office about your part of the bill. If the follow-up work on the wrong tooth was needed only because of the mistake, and you wouldn't otherwise have to pay for it, then tell your dentist you don't feel you should or will pay your part of the bill.

Our Rights Return
Our Rights Return