Real-World Healthcare

Episode Transcript

Speaker 1 (00:00):
Eight oh six thirteen ten Wi BA and full scope
with Wisconsin's directcare doctor doctor Nicole Hemkiss of Advocate MD.
The website for Advocate MD and it's a good one
Advocates DPC dot com. That's Advocates DPC dot com. A
lot of great information there to learn more about direct primarycare,

(00:20):
what it pairs well with, also some great stuff. If
you are an employer looking for options for your employees,
you can learn more about direct primarycare and Advocate MD
at ADVOCATESDPC dot com. That's ADVOCATESDPC dot com. Also, if
you're looking for something for yourself or your family when
it comes to great primarycare, you can again you can
learn more online ADVOCATESDPC dot com. To make it a point,

(00:41):
become a member at Advocate MD six oh eight two
six eight sixty two eleven. That's six soh eight two
six eight sixty two eleven. And joining us this morning
is doctor Nicole Hemkiss of Advocate MD.

Speaker 2 (00:52):
Doctor.

Speaker 1 (00:53):
How you doing this week?

Speaker 2 (00:54):
I'm doing well, Shaan. I'm glad it's Friday. I bet
you are with you.

Speaker 1 (00:59):
I am I am the in the exact same position
as you. I cannot wait to get to the weekend
looks like a nice one ahead as well. And it's
a great weekend too for folks that are you know,
and just kind of a great day to start thinking
about direct primary care and I and take some action.
I know we've for folks that are our regular listeners
to the program, they're probably very familiar with Advocate MD,

(01:22):
but maybe you haven't taken the opportunity to make that
appoint become a member. It is a great day and
a great weekend ahead to be to be setting that
stuff up. And again, all I gotta do is call
six two six eight sixty two eleven to start that
start that membership, become a member an Advocate MD. And
before we get rolling on this week's conversation about the
insurance scam and what happens with insurance and some we'll

(01:43):
get some actually first hand experiences dealing with some of
these some of these systems. Let's really quickly talk about,
of course, the locations of Advocate MD, the OG the
original one west side of Madison, right on Glacier Ridge Road,
east side location in Madison, the Rock County location right
in Janesville at ten twenty one mineral point app and
the newest location doctor right in Fitchburg on Syin Road

(02:06):
at thirty two to twenty Seigne Road. That is just
a beautiful, beautiful and very convenient location for folks, isn't it.

Speaker 2 (02:13):
Yes, Yeah, it turned out really well, and it's easy
for people that kind of live on the south side
of Madison or you know, the surrounding areas like Stoton
and Oregon, and we have a lot of patients coming
from there. It's like five minutes off the belt line,
so it's easy to reach from different places.

Speaker 1 (02:29):
It is a really really nice location again for convenience
as well as folks haven't had a chance to kind
of go back. There's a beautiful nature preserve. It's just
a really nice and all the clinics at advocatet MD
are absolutely fantastic, really really nice, nice clinics of Advocate
MD and fantastic doctors as well. And I think eight
physicians at Advocate MD if I remember correctly. And of

(02:51):
course Jennifer Filbin one of the newest doctors at Advocate MD,
and she is up and running, isn't she, doctor.

Speaker 2 (02:59):
Yes, doctor Philbin, I think now just completed her third
week with us, so we're very excited to have her.
She came to us from Lake Mills, where she was
part of Fort Health for many years, I think about
a decade, so it's exciting to have a new doctor.
She primarily works at the East Madison location, but she
does also work in Fitchburg and Janesville on certain days,

(03:19):
so she is enrolling new patients. Also, doctor di Giovanni's
enrolling new patients and doctor Dan, So we still have
choices of doctors that you can see. And people always ask, well,
as you get busier and you know, the practice grows,
like how are you able to still you know, keep
the same level of service of access. And that's because

(03:42):
we keep adding more doctors. So when a doctor kind
of gets to the point where they're feeling like they
want to be full and they don't want to take
on new patients so that they can still provide you know,
great care to their existing patients, then we try to
add another doctor so then they can take on the
new patients. And then we do have some some doctors
who are taking on very limited new patients so that

(04:03):
again they have a full panel, which in our system
is you know, maybe between four hundred to six hundred patients,
whereas in a traditional a large system like UWORSSM, that
would be two to three thousand patients. So we're talking about,
you know, like less than a quarter of what a
family medicine doc in the large systems is taking care of.
And that just allows you to have much more personalized care,

(04:27):
more time with the doctor, more access to a doctor. Again,
that's that's one of the reasons when people, you know,
I have this discussion so much Sean of like, well,
I have insurance, isn't this like redundant for my insurance?
And I'm like, well, absolutely not, because how many people
have insurance and it takes you nine to twelve months.
I mean I literally go through this probably weekly where

(04:47):
I might be sitting in a open enrollment meeting or
employee meeting and somebody will kind of raise their hands
and they'll ask about this, or they'll say, well, I
really I like my doctor. I've been going to the
same doctor for the last ten or fift ten. You'res like, well,
that's great that you like your doctor, but that doctor
can't get you in for an appointment for ten to
twelve months, So really that's not good care, right, Like

(05:10):
if it takes you ten months to see your doctor
when you have something going on, you basically don't have
access to medical care at that point.

Speaker 1 (05:16):
And one of the great things is, as you mentioned
with Advocate MD and Direct Primary Care, is you can
actually get in to see your doctor. When you need
to see your doctor, you make an appointment, you can
get in a couple of days. If it's obviously something
where you need urgent care other things. Doctors at Advocate
MD are there for you as well. But the cool
thing is actually seeing your doctor, not a you know,

(05:37):
a PA or whatever the other like the nurses you
literally get into Yeah, the nps, that's that's who they are,
and those folks is I can actually see your doctor.
Which is so cool about Advocate MD and great options
not just for you and your family, if you're an employer,
great options for primary care with with direct primary Care

(05:57):
and Advocate MD and doctor you talk a couple of
weeks ago just about about taking the kiddo in UH
A little bit of follow up because we talk about
insurance obviously, and even with direct primary care, you want
to have some type of catastrophic coverage insurance or a
health share. There is there is that there is that
role for that. Let's talk about kind of how that's

(06:19):
that's that visit has shaken out and and what you've
seen firsthand.

Speaker 2 (06:25):
God, yeah, wow, it's so funny because I don't live
in that world anymore. You know, I don't live in
the the large health system insurance based world anymore. Thank God,
I do, thank God every day for that. But so
so I really only have to enter into it occasionally.
You know, in this case, my older daughter, Margaret we

(06:47):
as I mentioned, I think that we usually doctor her
in our clinic. I have one of the other doctors
part of the clinic that would see her for her
you know, yearly exams or if there was anything acute
going on. But you know, I just I guess, I, I, well,
maybe it's good to reconnect with her pediatrician that she
hasn't seen in a few years, and you know, revisit
her and talk about a few things. So the the

(07:09):
appointment making process, so I guess, you know, it's it's
it's kind of funny. I have to laugh now, although
it's really not. It shouldn't be a laughing matter. Like
every stage of this process was difficult and frustrating, So
so to call to make an appointment with the pediatrician
that again she saw for many years. But it's been
a few years since we had seen her for a visit.

(07:31):
So I called there. They said, because it had been
more than three years, we were considered new patients. She
had to transfer me to a different number they had.
They said, they erased all of our information out of
the computer. We had to get all the new information.
I'm just like, what why? And then and then at
that point, so, so they are covered under their their
dad's insurance policy, and so they asked me for the

(07:54):
insurance information and I said, well, I don't have that,
so they would not make an appointment for her without
the surance information. I said, okay, well, can you just
put me down as a cash pay I can pay
cash if necessary, or we could bring the insurance card.
They would not do that. They would not schedule an
appointment as a cash pay patient. Then they said that
they would have to connect me first to something called

(08:16):
community connect or community cares, which would be something that
they would provide me with social resources to be able
to figure out how to pay for the visit. And
I go, no, thank you. I'm a physician in the
community here I can pay for pay cash for a visit.
I don't need that. No, this is our policy that
you know. So basically everyone's treated the same, everyone's you know,

(08:38):
it doesn't matter whether you say you want to pay
cash or not. So eventually, and again, even though I
asked to pay cash, I got the insurance information from
their dad and gave them that. So they have, then
when they get to the point where they can make
the appointment ten months to get an appointment with a
pediatrician ten months. So this must have been back in December,

(09:00):
so we were looking at like the following August to
get an appointment, and so I just was like what
And again, this is the insane part is that every
month you are paying a lot of money for your
health insurance, but you can't access it that month right
or the next month or the next month. You have
to wait ten months to access that care. So so

(09:21):
then I thought to myself, well, why don't you just
I know the pediatrician. I have her email address, So
I emailed her and she very nicely responded to me
and said she would get her in sooner. So again
I only have that access. I mean, I guess I
have some kind of loophole access because I am another
physician and I know doctors, right, so that maybe in

(09:42):
some cases it works, in some cases it doesn't work.
But we did go in, and then I think I
spoke about my experience with the whole self rooming self regime,
which is again somehow they flipped the script and made
this sound like this is something better for the patients, like, oh,
now you get to want through the hallways and figure
out where there is. It's kind of a challenge, right,

(10:04):
So we showed up and then you know, we were
told that we checked in at the front desk. I
think you have to check in at a computer screen too.
I honestly don't remember that part. But then we were
told to sit down because the room wasn't ready. And
I can't remember, but I think there's some sort of
a device almost like when you're going to a restaurant
and like they're they're telling you your table's ready or something.

(10:26):
But even at a restaurant, they have a hostess that's
actually taking you to the table, right, Yeah, they don't
just like point in that direction, say like go down
that hallway, make a left. So when they actually told
us that the room was ready. The front desk person
walked up there and so they said, okay, well now
we're doing this self rooming thing. So when you get
in there, look at the look at the board and

(10:48):
it will direct you of which hallway to go down
to and how to get your room. So they give
you I think a color and a number or something,
and I just was like in awe the whole time.
I was like, is this the twild Oh? What is happening?
So you walk into the front door. I mean I
already get lost. I mean normally, even if there's somebody
with you, but you walk into the front door and
it's kind of like when you're in a hotel and

(11:10):
it's ing you like rooms. You know, room ten through
twenty five is this direction, Room twenty six through fifty
is that direction? And then there's different colors or something.
So we had to wander around. We found the room.
You go into the room, it's empty, You sit down.
They tell you to shut the door. So you sit
in this empty room by yourself, and you hope that

(11:30):
you found the corrects room. And so then after I
don't know, five or ten minutes, it wasn't I don't
think a super long wait. Then the medical assistant comes
in to do the vitals and stuff. So that whole
thing was very bizarre to me, that whole experience. But
so then the pediatrician saw us and we had I
don't know, maybe a twenty twenty five minute visit with

(11:51):
the pediatrician. We really like her pediatrician. And I always,
as you know, Sean, I like to say that I
don't blame the doctors that are in the system for
the way the system is. I think it's a system problem,
not a doctor problem. Right, there are great doctors that
are trapped in large health systems that you know, are
either risk to risk, averse to leave, or you know,

(12:13):
just have been so ingrained into that one way of
doing things that they don't think that there's another way,
even though there is. So anyways, fast forward two months
and I get the bill from UW Health and I feel,
I mean, I'm calling this out because I can because
it's my own medical bill in my child's experience, and

(12:34):
I'm also going to post the bill on Facebook and LinkedIn.
But so we got the bill, and again I had
made this appointment somewhat aside from the normal routes. So
I thought it was going to be done as a
well child check, but it was not. It was done
as a new patient level one for and again just
to educate the listeners, the way our fee for service

(12:57):
medical system works when you use your insurance is that
there is an incentive on the part of that health
system to bill it at the highest level possible, right,
because that's how they are reimbursed. More, there is not
really any forethought to think, okay, well, when we build
this to a higher level, whatever the insurance doesn't pay,
then the patient is responsible for paying that, right, So
like we stick you with a higher bill. So this

(13:19):
was billed as a level one four, which is like
a moderate complexity visit. Again, I could talk for hours
about whether or not that was appropriate or not, but
I won't go there. But so, the total cost of
this twenty to twenty five minute, let's say, on a
I'm being generous, twenty five minutes, let's say twenty minute
pediatrician visit was five hundred and thirty five dollars. So

(13:40):
this was not a visit with a specialist. This was
not a minor procedure. This was a primary care pediatricians
office visit with a nine year olds for twenty minutes.
That was built at five hundred and thirty five dollars,
and I have to just keep saying that number because
one year's worth of one year's worth of direct primary

(14:01):
care for a nine year old would be less than
five hundred dollars in our practice. But one single visit
for twenty minutes. Again, that doesn't include any follow ups
or acute care or you know, if we needed lab
work or any of that stuff, or x rays. Just
the visit with the doctor in the room was five
hundred and thirty five dollars is what they build to

(14:22):
the insurance company. And then of that and again I'm
gonna post this bill so everybody can see it. The
contractual adjustment from Blue Cross Blue Shield was eighty so
they have agreed with Blue Cross Blue Shield to give
them that special discount you get right, So instead of
it being five hundred and thirty five dollars, it's four

(14:43):
hundred and fifty three. So it was approximately eighty dollars
they took off. But because of course, like most Americans,
we haven't met our deductible, we pay out a pocket
for that full amount, even though it was a primary
care visit. Which again you wonder if if your insurance
isn't even paying for them most basic level of care
like primary care, what the heck do you have this

(15:04):
insurance for. So they build it through insurance, and again
the insurance paid zero of this, but the final bill
was four hundred and fifty three dollars. So of course
I immediately called, and I'm immediately like, so, you know, I
didn't know that the I didn't first of all, didn't
know the bill the visit was going to be coded
this way. I thought it was going to be a

(15:25):
well child. I also didn't, you know, know that the
cost was going to be this high. And so now
I realized that it would have been better to pay cash,
which is, as I mentioned, that's what I originally wanted.
I asked them that we could pay cash for that visit,
because so when you pay cash in most systems, they
will give you anywhere from a thirty to fifty percent
discount for paying cash. And so so again, even if

(15:48):
you took it off that original amount, a thirty percent
discount at UW would have been less than the four
hundred and fifty dollars right probably about you know, three
hundred and fifty or something. So so I said, well,
can you build this as cash. Oh, I don't think
we can do that now because now it's been submitted
even though the insurance is pay zero. Now it's been
submitted through the insurance. I said, can you have them

(16:09):
relook at the coding on this to see if they
coded this properly? And again, this is kind of like
saying to somebody again, this system benefits. They profit off
of the fact that they code you at a higher level.
So maximizing the coding is kind of part of the game. Right.
So now I'm asking them like, oh, you might have
made a mistake. Can you please just double check on this?

(16:31):
And it's aff He's like, no, we didn't make a mistake.
Like they're not going to acknowledge any mistakes, right, So
believe me, Sean, I've been through this as you know.
This is something I'm passionate about. So if anything like
this happens to either one of my patients or me
personally or my family, I will take it upon myself
to like delve into this and you can fight this

(16:53):
with them, and they rarely, rarely ever make a change.
So you can request the medical records you can review
the medical records, you can say I don't think this
was coded properly. You can do all of that, and
they will rarely make a change that you know, they
can send you to the patient advocate. So so then
I had a thought. You know, so I had a
very frustrating phone call, of course, and I always say

(17:15):
to the person on the phone, like, I'm sorry, I'm
really frustrated about this situation. I don't mean to take
it out on you personally. I know that you're just
part of the system. You're just doing your job. I
get it, but it is a really broken, messed up
system right where where a twenty minute pediatrician visit is
five hundred and thirty five dollars, there is no way
in the world that it should be that much, you know.

(17:35):
So then I of course have the thought. I'm like, well,
I'll just reach out to her pediatrician, like she's a
reasonable person, like I'm sure you know, maybe this was
supposed to be built as a well child or maybe
you know there's something else that I'm missing here. So
I sent an email to the pediatrician again, who I
think is a very nice person. I think she's a
good doctor. And I got this response back that was

(17:59):
was literally that the words she used was SI, isn't
insurance terrible? And then proceeded to I mean that was
that was the first liner, and then proceeded to tell
me why that was coded properly and how it couldn't
be a well child and and how you know how
terrible insurance is. And I'm thinking, wow, So basically you

(18:20):
acknowledge that insurance as a scam, like it's scamming patients
out of money, but you have to kind of just
you know, be a part of it because like again
I I don't know. I don't want to. I don't
want to blame the doctors too much, but you know
what I mean.

Speaker 1 (18:34):
Yeah, Well, and I guess my as you know, we
talk about doctors and the patient relationship. And I would
have thought when you reached out to her, like Ben,
like Lizen, this is you know, because I know that
a lot of times doc and I think we've talked
to her. I probably have. You probably were the one
to talk about about this is like doctors will submit

(18:55):
things and there's literally people at the insurance companies that
are going over what submitted in making sure their coat
like kind of up coding to make sure that that
they're getting every penny squeezed out of patients as they can.
Remember years ago Christina telling me when I had just
like my routine physical or check up, she said, make
sure you do not bring up any concerns unless you

(19:18):
really have.

Speaker 2 (19:21):
Don't tell them about that chess pain or that.

Speaker 1 (19:24):
You know what kind of system is breathing.

Speaker 2 (19:28):
It is crazy because that's the way patients have been trained.
And I also probably have said this on the program before.
Health insurance is one of the only things where you
purchase it hoping to never have to use it, right
like you hope that you don't actually have to use it.
But so so anyways, then I called back to you
w a few days later, this was probably the beginning
of this week. Spoke to a different person in the

(19:49):
building office, and I think this was when I was
requesting again that they submit this so that I could
pay cash. And I also brought up the fact that
now there's all these and I don't know the names
of bills, the particular names, but there's all these fair
billing practices and laws about transparency of pricing because they
recognize that that patients get all these surprise medical bills, right,

(20:11):
and it's not fair. I mean, it is definitely not fair.
It's borderline legal, I guess. But so now mini systems
like UW Health, they are supposed to send you an estimate.
So you've probably seen this Sean or anybody that's gone
to UW Health. Before you even go in for that
doctor's appointment, that physical therapy appointment, that surgery, they're going
to send you an estimate of services. And again this

(20:33):
is based on them knowing ahead of time your insurance
coverage because they have all that because like I said,
they won't even make the appointment, so they've run that
through your insurance, they make sure they're in network, they
know what your deductible is, all of these things. And
so apparently they sent me mine, but they send it
to a my chart that I didn't even realize was
set up. But so they sent me the guess with

(20:54):
the estimates of the services for that one visit was sewn.
So the visit that ended up being five hundred and
thirty five five dollars, guess what the estimate of what
that visit was supposed.

Speaker 1 (21:03):
To be twenty five dollars one.

Speaker 2 (21:06):
Hundred and nineteen dollars. So it was it was like,
what is that for? More than four times greater than
what they estimated. So when I was talking to this
gentleman on the phone at UW the billing department, I said, so,
then the estimate you don't have to stick with that.
He's like, no, it's just an estimate. But you have
all my insurance information at that point, right like you

(21:27):
or they don't know how the doctor is going to
code that visit, but they have some idea, you know,
based on what the how the visit is scheduled and
things like that, and the age of the patient and
all these things. So I said, so you don't have
to stick Is there a certain percentage wise where you
have to be within that estimate? Nope? So then I
said to him on the phone, I go, so you
could give me an estimate, for example, that says, you know,

(21:49):
a CT scan is going to cost fifty dollars and
then it ends up being five thousand dollars and that
that there's no no recourse to that. No, that's that's correct.
The estimate has no there is no implications from the estimate.
So what the heck good is the estimate then like
what is the point, So so that again this is
all kind of smoking mirrors, and then them acting like

(22:12):
that they are actually you know, providing you with information
or you know it again and they can see from
my my chart that I didn't even you know, the
my chart that they said they sent it to, that
it wasn't ever even viewed. But so so after going
back and forth with them, they won't resubmit it to
the insurance. And then the other funny thing they said
to me when I asked if I could pay cash,
they said, well, no, now you can't pay cash because

(22:34):
we know that you have insurance. And I go, yes,
but I just don't want to go through the insurance,
like I just wanted to pay cash, and they go, well,
we know you have insurance, and that cash discount is
only for people that don't have insurance. And I said,
so I could have just told you I didn't have
insurance from the beginning. Then, right, It's all such it's
such a game. And again I tell I tell my

(22:54):
patients this in order to play the It is such
a scam that they are prepared, they are perpetuating on patients.
You have to play the game, right, That's what makes
me the most frustrated of all of this is because
I know how to play the game and I understand
the scam, and they still got me after all of that.
So that's the most frustrating part because then you really

(23:16):
have no recourse again. So then you know UW Health
will send a patient to collections over a forty dollars bill.
I know this, So they will send a patience to collections,
you know, and then they can be harassed by collections
even though they weren't really willing to try to understand
or to work with them on the bill itself or
to reduce the cost of that bill. They'll just go

(23:38):
ahead and send them to collections over it. So so
it's super frustrating, and I wanted to put it all
out there for patients or for listeners and let them
digest this and to say that there is a better way,
and there is a way in which you don't get
surprise medical bills. You don't get hardly any bills at all,
because your membership is covering you know, ninety percent of

(23:59):
what we're doing in the office and if we do
anything extra, so anytime you come in for a visit,
so if if my daughter had gone and seen one
of the doctors in our clinic for this exact thing,
she would have been built zero because she's a member
of the practice. So so if we do something like
lab work or an X ray or dispense some medication,
the patient knows the cost of all of that ahead

(24:19):
of time, and they can also say at that point, again,
you know, the labs are usually ten or twenty dollars,
but they could say I don't want to do those labs.
I don't want to do you know. Again, that allows
you to be an informed consumer because obviously, if I
knew ahead of time that this bill was going to
be five hundred and thirty dollars, I would have said
I would have had a second thought and thought, you
know what, I think, Actually, we're just going to keep
doctoring her at our practice. So it's it's super frustrating,

(24:44):
and I really feel for patients, and I fight these
things because I feel like if I don't fight it,
and I'm somebody that has the knowledge and the experience
to fight these things, nobody else will, right Like, I mean,
I feel for patients that are trying to navigate this
on their own, and I would also say that if
you're part of our practice, we help you with stuff
like this too.

Speaker 1 (25:04):
It's sad to say that, like a shady fly by night,
used car operations has seems to have better practices and
seems to even be more caring than a healthcare system.
But sadly that's kind of where we are, and it's
it's it's really, you know, really, I think for a
lot of folks eye opening when they've experienced that. And
as you mentioned, there is a much better way, a

(25:27):
fantastic option for you and your family. If your employer
looking for great options for your employee, make sure your
employees make sure you check out Advocate MD in Direct
Primary Care. You can learn more online ADVOCATESDPC dot com.
That's ADVOCATESDPC dot com. Today is the day. Don't go
another day, make an appointment become a member at Advocate MD.
Six oh eight two six eight sixty two eleven. That's

(25:49):
six 'h eight two six eight sixty two eleven. Doctor
hemkis always great chatting with you. You enjoy the weekend
and we'll do it all again real.

Speaker 2 (25:55):
Soon, you too, Sean. Thank you.

Speaker 1 (25:57):
More of Madison in the Morning is next year on
thirteen ten Blue I B A