Postby vilca11 » Sat Feb 22, 2014 12:07 am
Julie,
When you see a physician there are two scenarios possible:
a) you might see a physician in the physician office space that physicians lease from the Outpatient Facility b) you might see a physician in the Outpatient facility space. In the a) case all expenditure for seeing patients (equipment, tables, nurses, room, etc) are physician's expenses and are included in the "profee bill" - the charge that you are getting from the physician. And you are getting only one bill - from the physician.
In the b) case all expenditure for seeing patients are Outpatient Facility expense and physician is just rendering his "labor", for which he charges a reduced rate to you or insurance. In that b) case the Outpatient Facility is billing you or your insurance for their incurred expenses, which is called a "facility fee", usually small, $50 sounds about right. Therefore, you are getting one bill from the physician for his "labor" and one bill from the facility. Or, Sloan just combines these two charges on one bill.
So, the conclusion in your case is that this time you saw your Dr. K on the facility premises, that is why the facility charged you a fee. It could be very well the same space you saw Dr. K before, but it is possible that starting 2014 the agreement between Outpatient Facility and a Physician's Group at Sloan has changed and now it is a "facility space", so you will be getting this charge all the time. Profee (physicians) charge full fee only on their own premises, otherwise it is reduced and a portion of charges is charged by the facility that owns the space, technical personnel and equipment.
In a Physician Fee Schedule that every year is updated in the US, the allowable amount that insurance pays to a physician depends on the place of service that is reflected on the claim. Insurance sees Outpt and pays less to physician, but they must know to expect a bill from the facility, which they will pay according to a facility fee schedule (APC rate).
Anyway, talk to your insurance - a manager or supervisor, not with the rep and explain to them that you should not be appealing this, they should be paying it to the facility according to the APC fee schedule.
Good luck educating these people... Vilca
11/2005 CC stage 1, F,50yo@dx
Mod dif adenocar, MSS, APC, TP53, CEAs1.6-4.8
1/12 1met liver@Vena Cava, RFA, 3oxi,11 5FU
8/13 2 mets same place,SBRT
4/14 2 Xeliri+Avastin
5/14 Nano Knife liver same 2 mets
6/14 2 Xeliri, ADAPT
4/15 PET, 2 same mets,Cryo Liver
5/15 MJ Oil, Herbs, Suppl, ADAPT
10/15 PET, same area, doubled in size, high SUV
10/15 RH, HAI, visceral involv., no LN
2/16 red FF, 50% red dose FUDR, CEA trends up
3/16 CT, PET, MRI L.Lobe all in small tumors
4/16 No acceptable options, going home