Adventures in US Health Care - 1. Back in the USA

We recently moved back to the US after living in Switzerland for three years. Switzerland has high quality health care and it is superficially organized like the "new" US health insurance system. Everyone must have insurance. Everyone is eligible to buy a "basic" package of health insurance. No one can be refused. The system works well. Health care charges are regulated and insurance companies pay the standard charge promptly (usually to the person who has the insurance but with prior arrangement, directly to the provider).
We were covered by our insurance for four months after our return. I had not had a prostate exam for several years so I made an appointment with the urologist I had seen in the past.

I can only say that the US health care system is extremely dysfunctional.

I had an appointment for 9am and was told to arrive 30 minutes early to complete paperwork. When I arrived early I presented my paperwork and was told to have a seat and wait. No reason to be there 30 minutes early.
After waiting nearly two hours without any information or explanation, I was finally ushered to an exam room. No one made any apology or even noted that I had waited two hours for my appointment. (In contrast, a dental appointment the following week where the dentist was 5 minutes late resulted in profuse apology.)

Total history and exam time with the physician was about 10 minutes. I was charged using code 99245 which is intended for "Consult" visits:
To meet the requirements for an office consultation evaluation and management (E/M) service, consultation criteria must be met. According to the Medicare Claims Processing Manual (IOM Pub 100-04) Chapter 12.30.6.10, to qualify as a consultation service:
- A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patients medical record and included in the requesting providers plan of care in the patients medical record. The consultation service request may be written on a physician order form by the requestor in a shared medical record; and
- After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician."

Clearly this was not a Consult visit since there was no referring physician. I made the appointment directly with this urologist since I had seen him previously. It would have been more appropriate to code this as a "Established Patient" visit.

This visit was also coded as a "Comprehensive History and Exam, High Complexity Decision, High Severity Problem requiring 80 minutes of physician time." This is a gross overstatement of the visit on all counts.
-The History would be best described as "Problem Focused"
-The Exam is best described as "Problem Focused"
-The Decision-making could be described as "Straightforward" since everything was normal and this was a "Self Limited or Minor Problem" (actually no problem at all, just a regular exam). Coding guidelines for this visit would point to a 99211 code as most appropriate as it allows for 15 minutes of physician time and Problem Focused exam and decision making. Medicare payment for this code is approximately $18.00. Coding me as a "New" patient or advancing to a Level 2 visit (30 minutes, Expanded Hx, exam) for an Established Patient would have doubled the amount to $36.00. This is still quite a bit less than the original bill of $450.00 that I was quoted and which seems to be very much too high for the service I received. I was offered a discount from the $450.00 charge to "Medicare Rates" of $229.56 if I paid cash which I did.
I will also not be returning to see this particular abusive physician.

Observations:
Maybe one reason health care is so expensive is that doctors are grossly overcharging.