One of the biggest frustrations we have in the health care industry is due to patients not understanding their own health insurance benefits. Oftentimes, patients think that just because they carry insurance, that means that everything is covered and they don’t have to pay anything. Patients receive health care service and a month later they discover that their insurance doesn’t cover that particular service; however, instead of accepting the responsibility of paying, many patients fight, demand, and threaten the physician’s office staff to make the balance go away.

This phenomenon has gotten worse in the past twenty years or so. I subscribe to the theory that much of this mentality is due to the inception of HMO’s. In the beginning, HMO’s had either zero patient financial responsibility, or an exceptionally low out-of-pocket cost. People have been conditioned in thinking that health care is an entitlement. After about a decade, due to insurance companies (and employer groups) not being able to withstand the expense of higher utilization of “free” health care, they began to make the consumer more responsible by charging higher co-pays and not covering certain services. Unfortunately, most Americans expect the same Cadillac coverage without any additional expense (beyond their insurance premium and co-pay).

A major challenge in physician practices is to help their patient’s understand their insurance company’s reimbursement policies, all the while maintaining good will. Physicians are finding themselves having to develop various financial informed consent forms to assure that the patient understands that they may be responsible for some of the cost. Medicare has required this, in the form of Advanced Beneficiary Notices (ABN), for years.  Even so, we often hear patients state, “I signed it but didn’t read it.”  Or, “I was afraid if I didn’t sign it that I wouldn’t get the service.” Perhaps the days of accountability are long gone.

One of the biggest threats we hear from patients is that they will leave our practice if we don’t write off their balance. Not much that you can do about that. Health care is a business and we cannot pay the bills with altruism. In addition, it is fraud to bill the insurance company for services and write off the patient’s responsibility. Aside from financial hardship cases, routine adjustments of patient responsibility can get a physician excluded and/or fined by the government when it is a government program such as Medicare or Medicaid. Worst case scenario for commercial insurance is the insurance company dropping the physician from their network.

With lower reimbursements, practices really need to devote more energy in collecting all revenues due. The average overhead for a primary care physician practice is reaching 60%. There are no government subsidies for physicians, other than rural health care, community health care centers and native american health centers. More and more physicians are closing their offices, retiring early, selling their practices to hospitals, transitioning to concierge medicine, or going to cash only practices. This is devastating to primary care because of the physician shortage; however, many specialists are also getting hit hard as well.

• 16000 Initial Treatment, first degree burn, when no more than local treatment is required.
• 16020 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; small (less than 5% total body surface area)
• 16025 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; medium (e.g. whole face or whole extremity, or 5% to 10% of total body surface area)
• 16030 Dressings AND/OR Debridement of partial thickness burns, Initial OR Subsequent; large (e.g. more than one extremity, or greater than 10% of total body surface area)

These codes can be used in addition to an office visit; however, the office visit must be medically necessary and a modifier -25 must be appended to the office visit. An example of a medically necessary office visit would be to prescribe medications (such as antibiotics and/or pain medication, for example).

Rule of Nines Burn Chart for Adults

Rule of Nines Burn Chart for Infant

1)  If it is time for a well-child physical, perform the normal well-child physical and complete any paperwork during that visit.  The well-child visit should be coded using CPT 9938x-8839x series along with V20.2 diagnosis code.  If the child is eligible for this benefit, the claim should be paid.  Most health plans have a limit of one well-child visit per year.

2)  If the child recently had a well-child check and, if it is possible to complete the form using the information from the recent well-child check, go ahead and complete the form using that information.  This can be done free of charge.

3)  The last option is to have the child come to the office for a visit to complete the form and charge a CPT 9920x-9921x series code with a diagnosis code of V70.3.  The insurance company will NOT pay for this and the visit should be considered “Time of Service”.  The parent should be informed of this fact prior to the visit.

Let  me introduce you to AZZ Cardfile:

http://www.azzcardfile.com/

You can download a trial of this program for free and see how other people have used it by looking at collections that have been submitted:

http://www.azzcardfile.com/collections/

There are so many ways that this program can be used and one is only limited by their imagination.  The collections provide some ideas and may be useful to others.  Many people use this program for recipes (ethnic dishes, beverages, desserts, etc.) or a way to create a database of gift ideas.  One thing that I use this program for is to organize my professional letter and form templates for easy reference.

I have been recording our inbound and outbound telephone calls for over three years now and it is one of the best things I have ever done in my 25 years of practice management! The system I have was developed by OAISYS. They have two products, Tracer and Talkument. Talkument is more basic. I started with Talkument and upraded to Tracer about a year ago!

OAISYS

OAISYS provides call recording for telephone systems; both inbound and outbound calls.  This has helped me as a Practice Administrator in so many ways and it is difficult to list all of them in a short summary.  I plan to provide a complete summary in an upcoming blog post.  Bottom line, though, there is not one single resource that has helped me as much as their Tracer system for call recording.  I have enjoyed benefits in the areas of Risk Management, Human Resources, Patient Relations, Insurance and Accounts Receivable/Revenue Cycle management.

Greenbranch Publishing

I believe this is the leader for publishing in the healthcare industry!  Their publication, The Journal of Medical Practice Management, is, by far, the most professional and informative resource available in the medical industry.  Greenbranch, also, publishes a wide variety of books, audiobooks, podcasts, and newsletters.  They offer AAPC CEU’s for many of the audioconferences, as well. Greenbranch has co-developed Codapedia, with Betsy Nicoletti, which is a “free encyclopedia of medical reimbursement”.

Don Self

Very generous in offering his time and resources, Don offers a database of free documents donated by others.  This alone is a valuable resource to anyone in the health care industry!  Recently, Don authored a book entitled, “The Unfiltered Guide to Medical Office Management“; this is a comprehensive guide for many issues relevant to a physician’s practice.  Don is in the business of consulting with the medical community to increase revenue; however, he also educates by speaking at conferences, publishing a newsletter and offering webinars.  Also, check out his E&M Sliderule…sure to be a hit for physicians and coders!

POMAA

A professional organization for Office Managers created by Office Managers!  It doesn’t matter what your title is…Office Manager, Practice Manager, Practice Administrator, or Billing Manager; this is an awesome organization that provides education and networking to its membership.  POMAA has recently celebrated its second anniversary, and already has had two wildly successful national conferences (Baltimore and New Orleans).  The third annual conference in 2011 will be in beautiful San Diego, California. POMAA’s educational sessions have been led by industry leaders such as Dr. Laura Sachs Hills, Owen Dahl, Wendy Lipton-Dibner, Don Self, Maria Todd, PhD, as well as many others.  POMAA has something for everyone whether it be online specialty forums, listserve discussions, newsletters, and e-blasts.  POMAA is progressive having a presence on many of the top social media sites like Facebook, Twitter, and LinkedIn.  There is so much to say about POMAA, but it is better to experience all the offerings oneself and the membership fee of $110 annually is the lowest compared to other professional organizations and offers incredible benefits!

According to About.com, in providing Gardasil vaccines to young men, “the result would likely be:

HPV can cause genital warts in men that may lead to several types of cancer, including oral, penile and anal cancers.

As with most new immunizations, it can take up to a year for this to process through to the insurance companies before they create policies to cover the vaccines.  At this point, Gardasil is covered by most health plans for girls and young women; however, the same is not true for boys and young men.  The Gardasil vaccine is quite expensive and requires a serious of three vaccines over a six month period that could cost in the range of $650-800 for the entire series.  It is recommended that you verify with your health plan, beforehand, whether or not they cover this vaccine, especially for the male gender.  If they do not cover this vaccine, it will result in the cost being transferred to patient responsibility.

FDA announcement:  http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.htm

About.com:  http://cancer.about.com/od/hpvvaccine/a/hpv_vaccine_boys.htm

Certainly, there are cases that the physician has poor management skills or may not have the ability to achieve closure of an office visit with patients. Perhaps, the practice has a poor scheduling system. In defense of medical offices, there are many reasons for physicians running late that are beyond the physician’s control and not the intention to create dissatisfaction to the patient.

The top one is due to the inception of managed care, physicians are forced to see more patients in a day. Physicians would prefer to spend more time with patients to make sure that the patient has the physician’s undivided attention and to create a relaxed atmosphere rather than one that is rushed. Many physicians enjoy the teaching perspective and would prefer to educate their patients on prevention and/or management of their condition.

Secondly, the front office staff tries their best to find out what the patient needs to be seen for and schedule appropriately. However, patients don’t feel that they need to tell the front office what their issue is and say it’s something minor. Then, when they get into the exam room, the doctor comes to find that it is not minor and the patient really needed a thirty minute appointment instead of the fifteen minute appointment. We have heard many times, “It’s none of your business.” or “It’s personal.” Patients need to understand that we need this information to help prevent delays and by making sure that the physician is prepared to deal with the problem (equipment or supplies) prior to the patient’s arrival.

In addition, patients oftentimes throw in that “Oh, by the way…” which also adds to delay for other patients down the schedule. Many times, the patient comes in for a minor problem and when the physician asks if there is anything else, in an attempt to close the visit, the patient will add “While I am here…I’ve been having this chest pain for the past three days!”

And, lastly, we can never tell when there is an emergency that will delay us and we are not able to conveniently schedule them late in the day. Case in point, we had to have the ambulance come and pick up a patient who was scheduled for a 15 minute appointment for a medication check. The patient did one of those “Oh by ways…” which led the physician to determine that the patient was probably having a heart attack and the physician was not going to leave the patient’s side to see another patient.

Physicians are starting to limit appointments by telling patients that they can only have two concerns addressed, or they tell them that they were scheduled for A and that they only have time to deal with A, so they have to schedule another appointment to deal with B. This upsets patients even more than the delay. Ideally, staff should communicate with patients about any delays as soon as they arrive to check-in for their appointment, or as soon as they realize that there is a delay. This gives the patient an option to stay or reschedule the appointment. Though, patients still may not react favorably to this news, they would much rather have the opportunity to make that decision.

http://www.dol.gov/dol/topic/health-plans/cobra.htm

In “layman’s language”, COBRA is an extension of the insurance that a person had while they were employed.  The employee has group insurance through their employer. Typically, employers pass on some of the insurance premium to the employee while they are employed.  Historically, the vast majority of employers that provided insurance to their employees offset some of the premium as a benefit of employment, so the employee never actually realized the actual premium amount for the insurance coverage that he enjoyed.

Upon separation of employment, an employee is extended COBRA Continuation of Coverage; however, the employer passes the entire cost of the health insurance premium to the employee.  At the very most, the employer (or insurance company handling the COBRA requirements for the employer) can charge a 2% administration fee.

The fact is that health insurance premiums are very expensive.  If an employee only paid a nominal amount for their health benefits while they were employed, that just means that their employer paid a greater portion of the premium.  It’s unfortunate that the vast majority of employees don’t understand this concept, even after they receive their COBRA paperwork stating the total amount due for their health insurance.  Typically, people complain about the cost of COBRA as if they are being offered a completely different insurance that costs more than what they had.

No, folks, you are still enrolled in the very same health plan that you had while you were employed, but now you are responsible for the full premium and not your employer!

To illustrate further, I do my work and earn $100.   Tomorrow, I fill in for someone else and do their work and earn $100.  Okay, that seems fair. Tomorrow, I not only do I do my job, but I also completely do someone else’s work.  As an independent contractor, should I receive $100 for my normal work and that’s it?  Should I receive $200 for a double workload?  How about if I only get $150…$100 for my work and $50 for completing someone else’s job?  I think many of us would say that I should receive $200!

Unfortunately, many physicians are experiencing the $150 example from health plans when it comes to providing medical care on the same day as a preventive medicine visit.  According to universal coding principles, it is expected that a physician will code an evaluation and management (Office Visit) for diagnostic (medical) issues when done on the same day as a preventive medicine (complete physical).  One of the primary reasons is so insurance companies do not have to reimburse for services outside their reimbursement policies; for example, if the patient does not have preventive medicine benefits but comes in for a physical, the physical can not be coded as a covered medical benefit just to get  paid.

In physician coding, we are trained to code all services accurately to represent what actually was performed and documented so as to not open the practice up to the risk of fraud and abuse allegations.  In theory, one would think that if there is a universal coding policy, then the service should be reimbursed in a consistent manner; however, this is not the case.  What we are seeing is that the majority of health plans will pay the problem visit at 50% and the physical at 100% (there’s your $150!).  A few others will not reimburse the problem visit at all on the same day as the physical (you only get $100…double the work at the pay of one job!).  Consequently, many physicians are telling patients that they cannot have both services performed on the same day, thus the physician is able to get full reimbursement for each service (aha! that’s where I put my $200!).

It is inconvenient to the patient to make two appointments; but with the increasing expenses that physician’s practices are having to absorb, it is just not possible to throw away all or half of a reimbursement.  In addition, it is inconvenient to other patients who are not able to get in to be seen because of the physician’s full schedules…or doing in two visits that which he can do in one.  Understandably so!  The physician should be reimbursed for all of his services fairly.  This will allow the physician to be able see additional patients who require medical attention and not play insurance games!