Health insurance is very complicated. At our practice, we deal with health insurance all the time and even for us, it gets to be very complicated sometimes. So it is natural that patients have a hard time understanding it as well.

Therefore, I decided to summarize a conversation I had with a patient in an effort to help other patients understand, at the very least, a portion of how medical health insurance works.

At a restaurant, generally you’ll get an itemized check that shows all the things you’ve ordered. Doctors do the same thing, but they do it in the medical chart.

Virtually every doctor who accepts health insurance uses codes called CPT codes that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these services are “coded” separately.

These codes are used by the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. In other words, the health insurance company (the one actually paying for the services) wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does has a code.

For example, if you are coming in for a child’s well visit, the pediatrician will submit a “claim” to the insurance company using the following codes:

Established Well Visit – 99392
Developmental Testing – 96110
Hemoglobin – 85018
Finger/heel/ear stick – 36416
Lead Testing -83655
Hearing Screen – 92587

If the child gets immunizations, the vials have codes too.

DTAP-IPV – 90696
Flu – 90660

Vaccine administration also uses a distinct set of codes.

Admin – 90460
Admin – 90461

Let’s say while you are in the examining room with your child and you ask the doctor, “Ya know doc, little Lisa has been pulling on her ear lately… she may have an ear infection. Can you check that for me really quick?”

This question requires the doc to perform an entirely different assessment than the well visit the child was getting.

The doctor, in order to show the insurance company that she did a completely different assessment, codes the ear pain diagnosis and adds a 99213 – which is an evaluation and management code that documents in the chart and on the claim to the insurance company that the doctor also checked the patient’s ear.

Parents often think when they are looking at the bill that the doctor is nickel-and-diming parents, when in reality, it is the insurance company that requires the doc to show their work in this matter.

The health insurance company doesn’t accept the doctor telling them, “I did a well visit — pay me our agreed-upon fee.” They want to know all the things the doctor did during a patient’s visit so they can decide how much they ought to pay the doctor for his/her services.

Since most patients don’t pay the doctors directly, but rather the health insurance company, they want to know what took place during the visit so they know how much they ought to pay the doctor.

It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra.

Health care services is a la carte as well.

Brandon Betancourt manages a pediatric practice and blogs at Pediatric Inc.

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