It appears that the Health Care bill has passed the house. Now, it will be introduced to the Senate for further debate.
KTAR.com – House passes health care bill on close vote Saturday, Nov 7 2009
Health Care Reform and Health Plans and Insurance Health Care, Health Plan, health reform, Insurance 10:42 pm
New Trick by the Health Insurance Industry Tuesday, Nov 3 2009
Health Care Reform and Health Plans and Insurance and Preventive Medicine Coding and Reimbursement Billing, Coding, Health Care Reimbursement, Health Plan, health reform, Insurance, insurance reimbursement, physicals, preventive medicine, Reimbursement 8:39 pm
Imagine that you are an independent contractor for a company that pays you a specific rate for a specified amount of work; however, if you do more than the specified amount of work you would receive an additional amount. Now, if you were to do that additional amount of work separately you would receive 100 dollars. But, if you do that additional amount of on the same day as your normal work load, you would receive your normal pay for your normal work load and 50 dollars for the additional amount of work. Would that be acceptable to you?
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!
Woman charged extra for asking doctor too many questions Saturday, Aug 8 2009
Health Plans and Insurance and Preventive Medicine Coding and Reimbursement Billing, Coding, Health Care Reimbursement, Health Plan, Insurance, insurance reimbursement, pap, patient, physicals, physician, Physician Practice, preventive medicine, Reimbursement, well woman exam, Well-Woman 8:43 pm
Woman charged extra for asking doctor too many questions | 3 ON YOUR SIDE |
Arizona | azfamily.com
by Gary Harper/3 On Your Side
August 5, 2009
A Valley woman says she has a billing problem with her doctor’s office.
The billing problem has to do with a “well woman exam,” basically it is an annual physical for women.
The woman you are about to meet says it was supposed to be covered 100% by her insurance carrier, so why does she keep getting billed by the doctor’s office?
Shannon Karal, like a lot of women, knows the importance of having an annual physical. She says, “I do all my preventative visits for dentist, doctor, any of the normal things I try to go as much as they say you should go.”
So Shannon scheduled a well woman exam at a physician’s office called Doctors Goodman and Partridge, an exam she says that is 100% covered by her insurance carrier. Shannon explains, “I just had some questions and concerns about normal things that a young woman like me would have.”
Shannon says the exam was completely paid for by her insurance, however, she keeps getting a bill for $92 from the doctor’s office so, she called to find out why and, according to Shannon, she was told she asked too many questions during her exam.
She admits, “It makes me feel like next time I go to the doctor I shouldn’t share any of my questions or concerns or take any more time out of their day because I might be charged extra for that.”
Shannon maintains the questions she asked during her exam were all normal “female-related” questions and she cannot believe she would be charged. “I would completely understand this extra charge if there was another test done or something they do for my questions. But nothing! It was all verbal.”
The office of Doctors Goodman and Partridge would not talk to 3 On Your Side about Shannon’s case citing privacy issues but after our inquiry, they sent Shannon a letter saying, “The problems evaluated and managed at that visit were above and beyond the scope of a normal well woman exam” but, Shannon says that is nonsense and feels she is being billed for asking too many female-related questions, and taking up too much of the doctor’s time. Shannon tells 3TV, “I feel like there’s a stop watch every time I go to the doctor and they’re gonna be timing me and making sure I don’t go over that time and if I do then ‘Oh, there might be an additional charge for this.’”
Americans on Healthcare Reform: Top 10 Takeaways Saturday, Aug 8 2009
Health Care Reform and Health Plans and Insurance Health Care, Health Care Reimbursement, Health Plan, health reform, Insurance, insurance reimbursement, Reimbursement 7:52 pm
Side-by-Side Comparison of Major Health Care Reform Proposals – Kaiser Family Foundation Saturday, Aug 8 2009
Health Care Reform and Health Plans and Insurance Health Care, Health Care Reimbursement, health reform, Insurance, insurance reimbursement 5:12 pm
This is a useful resource if you are interested in comparing all the proposals and/or specific topics.
Side-by-Side Comparison of Major Health Care Reform Proposals – Kaiser Family Foundation
Achieving comprehensive health reform has emerged as a leading priority of the President and Congress. President Obama has outlined eight principles for health reform, seeking to address not only the 45 million people who lack health insurance, but also rising health care costs and lack of quality. In Congress, a number of comprehensive reform proposals have been announced as the debate proceeds over how to overhaul the health care system.
Helped Patient Battle Health Plan and Won! Sunday, Jul 5 2009
Health Plans and Insurance and Reimbursement Billing, Health Plan, Insurance, insurance reimbursement, patient, Physician Practice 9:36 pm
Just about a week ago, I received a call from a patient who was extremely upset that she was being billed $1,400.00 by the imaging facility for a CT scan after we told her that she did not need a prior authorization from her insurance company. Typically, this is one of those things that it’s our word against the insurance company and, historically, the insurance company seems to always win. I guess the axiom “he who holds the money has the power” applies in this kind of situation. The insurance company insisted that they did not have a record of our phone call to them and that they would never have told us that this patient did not need a prior authorization for the CT scan. The patient was irate and understandably so…especially with the economy the way it is. As a goodwill gesture and to keep peace with the patient, I would have accepted the responsibility and paid for the scan and our office would be out the money.
But…we voice record all our incoming and outgoing telephone calls using a system called Talkument. I have all of the staff and physicians trained on what information is helpful to me when I need to investigate a telephone conversation. In this case, I pulled the patient’s chart and the medical assistant wrote a note stating that she called the health plan on 5/23/09 at 3:13 pm and found out that no prior authorization was needed and that she talked with Ann. I knew my medical assistant’s extension and searched based on the information that I had, and viola, I found the four minute telephone conversation between my medical assistant and the health plan representative, Ann, who said that the patient did not need a prior authorization for the CT scan!
I had a three way conference call between the patient, myself and the health plan where I played the recording for them. The patient was ecstatic! I had to play this information a couple of levels up the ladder and was still told that someone would have to get back to me (quite frankly, I don’t think they were ready to address the fact that the doctor’s office actually had recorded them! Uh oh! They were caught!)
About a week later, the health plan representative called me and stated that they would cover the cost of this CT scan “this one time”. She still did not want to take responsibility for her company giving inaccurate information. She made it sound like we doctored up the recording…even though we have caller ID that had the health plan’s toll-free number and the first two minutes of the recording was the automated system that announces the health plan name. I was even told by the rep that the person with whom my medical assistant had talked with, Ann, was not an employee of this health plan. I love the lack of accountability!
Defensive medicine is taking on a new definition. Besides the Internet, the next best resource I have in my office is the voice documentation system for phone call recording! The system has aided me with staffing issues, patient issues and now insurance issues. It has definitely paid for itself in protecting my physicians and our office from lying and deceit.
BLOG REVIEW: “Are Doctors Infected With The Stockholm Syndrome?” Saturday, May 2 2009
Reimbursement Health Care, Health Care Reimbursement, Health Plan, Insurance, Medicare, Reimbursement 10:57 am
A companion blog for The Yale Journal for Humanities in Medicine (http://yjhm.yale.edu)
Tuesday, February 17, 2009
Are Doctors Infected With The Stockholm Syndrome?
Medicare is a great social institution. It saves millions of people from financial destitution.
But many doctors feel unfairly treated by Medicare’s payment schedules. For the past two years Medicare has threatened to cut physician reimbursement by 10% in 2008 and by 20% in 2009. After an outcry from physicians, the cuts were eliminated and physicians were given increases of .5% and 1% respectively. Many physicians were relieved to see that the cuts were reduced and some groups including the AMA actually thanked the Medicare Payment Advisory Committee (MedPAC) for being so understanding.
But rather than thank Medicare for the tiny increases which some consider an insult, it would have been better if medicine’s leadership had preserved physicians’ honor and dignity by rejecting them outright.
This pattern of being threatened then given a small reprieve followed by thanking the oppressors bears great similarity to the so-called Stockholm Syndrome which Webster’s New World College Dictionary defines as a psychological state in which hostages sympathize or even become friendly with their captors.
When threatened by severe price cuts that seriously jeopardize their livelihoods doctors may not be kidnapped or locked in closets but they are hostages none the less. And thanking those who oppress them for being so understanding makes them victims of the Stockholm Syndrome.
Clearly, to go from a 20% cut to a 1% increase represents quite a difference in any physician’s income. But still, groveling before Medicare and thanking it for a puny 1% increase is wrong. This weak showing is sure to encourage private insurers to use the same strategy. By threatening to drop doctors from their lists for failure to conform to their standards for quality and cost-efficiency, private insurers will have another tool to control doctors. This control will become acute once electronic medical records are in place and every treatment, test, and consultation ordered by physicians will become instantaneously available to health insurers to see who conforms to their protocols and who doesn’t.
Far better for the future of medicine if its leadership had rejected Medicare’s 1% increase and dedicated the savings to lowering patients’ premiums.
Ed Volpintesta MD
_______________________________________________________________________________
My comment:
This is very true! I think that this was premeditated by Medicare. They knew physicians would not accept a small increase of 0.5% or 1%, so how do you get the health care industry to accept it? Threaten a huge decrease in reimbursement and then come back at the 11th hour with the intended puny increase and act like you are doing physicians a favor…Medicare is a “hero”! It’s crazy, but it has worked for years now.
Physicians are too busy to fight it because they have to see more and more patients to make ends meet. So, the insurance companies, including Medicare, keep reimbursements low and physicians have to work harder, see more patients in an hour, and focus on documenting the notes to achieve adequate payment. Now, we are seeing P4P…Pay for Performance…to get any further increases in reimbursement. Sounds great right? Is it really an increase? I don’t think so. To improve performance, the physician must reduce the number of patients seen and document more performance measures, which means their reimbursements will go down because they are not seeing as many patients as they did. So, the increase will bring them up a bit IF they can prove that their performance measures are having a positive effect. Sounds to me like the physician is working differently to receive the same amount of pay.
We are also looking at reimbursement incentives to implement Electronic Medical Records; however, this typically has made the physician slower and decreases the amount of patients that they can see in a day. How is that effective for the bottom line? The cost of EMR is extremely expensive. In my practice of seven physicians, we are looking at over $100,000 to purchase an EMR. How do we pay for it if we are seeing fewer patients each day?
Unfortunately, the government and insurance companies are developing regulations and policies without input or direct knowledge of how things actually work in a private practice. In addition, there is no consistency between health plans, so it takes more employees to appeal denials and keep up with all the specific reimbursement policies.
Physicians in private practice are getting the life sucked out of them. Insurance companies have created patient antagonism toward their physicians. Society is pointing fingers at the cost of health care and implying that is the fault of the provider of services. If that is the case, why do physicians make $100,000 to $300,000 a year, while insurance company executives make near a million or considerably more per year? Why do the insurance premiums continually increase for both the patient and the employer, while the provider of service sees either flat or decreasing reimbursements? Yet, insurance companies post health profits each quarter.
Charlene Burgett, M.S.
