Is there a difference between a “Biller” and a “Coder”? Saturday, May 30 2009 

Many practices are stymied by the difference between a “biller” and a “coder”.  Why would a practice need both?  Are there any other alternatives?

Well, there is a major difference and it is possible to find one person who can do both…if you are lucky!

A “Coder” is trained in CPT and Medicare coding guidelines.  They should understand Documentation Guidelines in determining coding for Evaluation and Management services.  In addition, they are trained in coding HCPCS and ICD-9, as well.  The coder is usually more “black and white”, they look at coding as somewhat of an exact science.  The problem that I see is when you put five coders in the same room and ask them to code the same thing, you will probably have five different answers!

The “Biller” will be more the “gray-area” thinker.  They see how claims are paid by each health plan.  They know that each health plan has their own reimbursement policies and that the “rules” are consistently inconsistent.  They may not be as well versed in the exact coding of services, but they know how each health plan reimburses specific codes and coding combinations.  If I have a question regarding how a specific health plan reimburses an office visit on the same day as a preventive medicine visit, I will ask my Biller.

Typically, you will find that an employee has either a “coder” or “biller” perspective.  Each are good and needed by physicians; however, there are some people out there who have both perspectives and they are Golden!  If a practice is fortunate enough to bring on an employee with both viewpoints, they will have a valuable asset on staff.


Rating physicians on websites Sunday, May 24 2009 

I’ve been troubled by the fact that patients can go to websites that allow them to rate their physicians and add comments. The main problem is that physicians can not defend themselves on these sites without breaching patient confidentiality. How is it fair for someone to provide a one-sided statement that usually is derogatory toward the physician or practice and we can not refute the claims by giving our side of the story. Who can make an informed decision based on one person’s claim of being treated poorly or unfairly?

There is always another side to the story! What is not being told is that the disgruntled patient may have wanted something that violated policy, the physician’s license, or the medical practice act. Perhaps the patient was abusive toward staff and was discharged? Maybe the patient just didn’t want to pay their bill and became upset that the practice sent him to collection? I can definitely say we have had our share of demanding patients who “want what they want when they want it”, otherwise known as the Burger King mentality. They do not want to go along with our rules and policies. They dont care that it was against the medical practice act to provide a prescription for something that the physician never treated them for.

I believe that anybody who looks at these rating websites really take it with a grain of salt. More often than not, satisfied people rarely go out of their way to find one of these sites and give their feedback. The patients who are fired up to get revenge are the ones that frequent these sites on a regular basis. Just think about how many patients a physician has and if you go to one of these rating websites and see 2 or 3 negative comments, is that really bad? Can you trust everything someone else tells you? What is their motive? Did that person have any part of the conflict? Have you ever met someone that was adamant that they were right about something and would not have an open mind to accept anything beyond what they believed?

Wall Street Journal article Saturday, May 23 2009 

I recently read this article in the Wall Street Journal. The intended audience are patients; however, I think that the comments are very informative to see the physician side of the equation. Yes…of course…I had to add my say and have commented on a variety of other people’s comments!

Why Patients May Be Billed for Free Exams
Coding-System Confusion Can Cause Insurers to Deny Coverage of Preventive Care

Wall Street Journal
MAY 21, 2009

Do I need to hire a bouncer for my medical practice? Sunday, May 10 2009 

The bad economy has resulted in many people losing their jobs, their homes, and/or their insurance coverage. People are overly stressed and panicking; resorting to actions that they would probably not have done under normal circumstances. One such response that I have seen increase in my practice is disrespectful behavior and abuse by patients toward me, my staff and the physicians.

The staff is trained on appropriate “customer” service techniques and they know that if they cannot diffuse the situations they need to ask for assistance from a supervisor. There have been extreme situations that require me, as the Administrator, to intercede. I can remain calm and in control in just about all situations. Confrontation, though not sport, is not something that I fear. I have had several experiences, however, that have given me pause.

One such moment was a result of a patient who demanded that we change his name in our computer system from his legal name to the name he preferred. His insurance card and driver’s license both had his legal name. Our system only allows one version of the patient’s name. Because it is mainly for billing, we have to use the name that appears on the patient’s insurance card or the claim would get denied. Several people attempted to explain this fact in a calm manner; however, the patient was very adamant. The front office supervisor called me to discuss the issue with the patient and, again, I proceeded to explain the reasoning behind using his legal name. I suggested that he notify his health plan and have them change his name on his insurance card and we would be able to accommodate his request. Apparently, he did not find that to be a reasonable suggestion and became increasingly irate and lunged over the counter at me, while yelling. As I was backing up, I asked him not to lunge toward me. He continued to yell, adding that he wasn’t lunging, all the while he is halfway over the counter hands flailing in the air.

On another occasion, a male patient wanted the medical assistant to code his labwork with a diagnosis code that would be covered by his insurance; however, it was not an accurate code for the services provided and not something approved by the physician.  She tried to explain this to him and he verbally assaulted her in the hallway on the way to the lab.  I was notified of this episode and confronted him about what had transpired.  He was very aggressive.  He proceeded to tell me that it was none of my business, even though I introduced myself as the Administrator of the practice.  I explained that what he did was not acceptable and his language was offensive and that is why it is my business.  I asked him to explain what had happened so I could attempt to respond to his concern and attempt to rectify the problem.  He proceeded to explain the request for the code change and that the medical assistant would not comply.  Unfortunately, I could not grant his request and attempted to explain the reasoning behind it.  His anger level rose another level and he yelled that I was supporting my employee and I was not providing “customer” service.  Vulgar name calling began spewing out of his mouth.  As I was trying to get him to calm down, I saw his right arm cock, fist closed, and knew that I was about to receive a blow.  Luckily, I was very aware of my surroundings and had my peripheral vision in tune…I backed away, picked up the telephone and called the police.  The patient left the office screaming.

These are just two of the more extreme examples of what I have personally experienced.  I fear for the safety of my staff, the physicians and myself.  Recently, I installed security locks on the doors between the reception area and the back office.  The ones that require someone from the back to “buzz” the door to unlock it.  About a year ago, I installed panic buttons at check-in and check-out.  When depressed, an alarm sounds and an immediate call notifies the police department.  I have only had to use the panic button once, but that was for an employee who was not happy that she was terminated and would not leave the premises.

I remain concerned and cautious regarding the safety in our office.  The threats are ever increasing, some of the known causes of these threats include:

  • Insurance companies creating an antagonistic reaction in patients toward their physicians.
  • Entitlement mentality that health care is a right.
  • Poor economy and resulting financial problems experienced by patient.
  • Belief that physicians are “rich” and the patient needs the money more than the physician.
  • Narcissistic society, “I want what I want when I want it and I am not accepting no for an answer!”.
  • Our society has entrenched the “squeaky wheel” mentality and many people start out with that approach.

I don’t have the answers.  I am very interested in hearing other people’s stories, recommendations, and thoughts to improve safety.  Please comment!

Thinking…. Thursday, May 7 2009 

I haven’t updated my blog lately…I am trying to think of what to post next and I have been trying to catch up with work and home stuff. I hope to add something this weekend. Please bear with me!

Thanks for your interest! Keep those comments coming in!!!!

BLOG REVIEW: “Are Doctors Infected With The Stockholm Syndrome?” Saturday, May 2 2009 

A companion blog for The Yale Journal for Humanities in Medicine (

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.